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Seminar on Taking Stock of the Condom in the Era of HIV/AIDS

Gaborone, Botswana, 13-17 July 2003
Organised by the IUSSP Committee on Reproductive Health and the University of Botswana

Report

The IUSSP Committee on Reproductive Health, in collaboration with the Department of Population Studies, University of Botswana, held a seminar, "Taking stock of the condom in the era of HIV/AIDS", in Gaborone, Botswana, on 13-17 July 2003. The seminar was supported by UNFPA, three departments of WHO (Reproductive Health and Research, HIV, and Child and Adolescent Health), Cornell University, and the University of Botswana.

The 37 participants included demographers, epidemiologists, service providers, anthropologists, and policy analysts; nearly half were African (16), but major contingents came from Asia and North America (seven each), and the remainder from Europe, Australia, the Middle East and Latin America. All career stages, ranging from PhD students to senior researchers, were represented. Forty per cent of seminar participants were women.

The broad goals of the seminar were to measure the extent of condom use for contraception and for disease prevention, to investigate the predictors of condom use and non-use, to enumerate barriers to condom use, and to explore implications for interventions. Based on the 30 abstracts and papers that were accepted for presentation at the seminar, the sessions dealt with measurement issues, the contraceptive condom, young people as users, regular partners as users, use by members of special groups such as prostitutes and the military, personal or cultural barriers to use, institutional barriers to use, and technical issues. Most papers were pre-distributed, and each session had a discussant and at least half an hour was devoted to participant discussion. The final afternoon of the seminar was devoted to discussion of the implications of the seminar papers for interventions and for further research.

Some major themes that repeatedly emerged in papers and general discussion were the multiplicity of barriers to condom use, the importance of promoting not just condom use but consistent use, and the desirability of special household surveys that also collect bloods.

The Sessions

A scientific review of the literature on condom use (Hearst and Chen) served to introduce the meeting. Major focuses of the paper were the importance of consistent use, the actual measurement of consistent use, and the lessons that can be drawn from the condom success stories of Uganda and Thailand, different though they appear to be.

Session 1. Measurement issues
Measurement issues are critical to the evaluation of potential and actual effects of condom use in stemming or reversing the HIV epidemic. A microsimulation model of the effect of condoms in preventing the transmission of STDs and HIV (Bracher et al.), incorporating a mix of behavioural, biological and aetiological data, and a range of values of condom slippage or breakage, highlighted once again the importance of consistency of use. In an investigation of the worth of survey questions on the time since last sex with a non-cohabiting partner and whether a condom had been used, a second paper (Slaymaker and Zaba) used recent Demographic and Health Surveys data from five African countries in an attempt to estimate men's coital frequency and thereby create a measure of condom use that accounts for differences in coital frequency. Discussion focused on the need for better data and on the potential worth of new, specially designed surveys.

Session 2. The contraceptive condom
The condom was instrumental in the historical European fertility decline but since the advent of hormonal contraception is now little used anywhere for contraceptive purposes. The organizers' intention in soliciting papers on the contraceptive condom was to elucidate the conditions under which condoms might be acceptable as agents of family planning, and to attempt to draw lessons relevant to the advocacy of the condom for disease prevention. Three papers were presented, on Lebanon, Tunisia, and Bangladesh. That on rural Lebanon (Kulcyzki) demonstrated very low level of condom use within marriage either for contraception or for HIV/AIDS prevention. Barriers to use included socio-cultural factors such as women's seclusion; misconceptions about the condom, husbands' unwillingness to limit family size, reduced sexual pleasure and marital intimacy, and social stigma.

Session 3. Who are the users (or non-users)? Young people
Young people comprise a group that is particularly vulnerable to both HIV (and STI) infection and sexual exploitation. A comparative study of 20 sub-Saharan African countries (Bankole and Singh) showed high levels of sexual activity among young men and high levels of sexual multi-partnership but relatively low levels of condom use. Encouragingly, condom use was more likely when individuals engaged in risky sexual behaviours. Much of the discussion focused on inter-country variation, which was considerable. Next, a single-country study of Mozambican youth (Prata et al.) demonstrated first, that many young people do not correctly assess their level of risk of HIV infection, and secondly, that although condom use is increased when people correctly assess themselves at risk, the increase is not dramatic. Finally, in a study of low-income adolescents in Buenos Aires (Zamberlin), there is widespread knowledge of the dual protection role of condoms, but use for pregnancy prevention is still very low because contraception is seen as the female partner's responsibility.

Session 4. Who are the users (or non-users)? Regular/married partners
The five papers in this session all dealt with sub-Saharan Africa (respectively Zimbabwe, Senegal, South Africa, Kenya, and Uganda). The extent of condom use within regular partnerships varied from study to study, was generally low, but tended to be used more for protection against disease than pregnancy. Condoms were used more with casual than regular partners. Each of the papers judged the promotion of condom use for dual protection as extremely important although each additionally recognized the difficulties in such promotion given the existence both of more effective family-planning methods and of barriers to condom use within regular partnerships.

Session 5. Who are the users (or non-users)? Special groups
The special groups considered in this session comprised prostitutes (in Bali, Indonesia, the Philippines, and Mumbai, India) and the military (Botswana and Togo). Prostitutes' awareness and use of condoms rose in each case over the period of observation although the latter two studies, which practiced active intervention, reveal how great the gap between actual and ideal behaviour remains. The papers on the military, who are often the clients of prostitutes, provided an interesting contrast. In particular, a lively paper on the Botswana Defense Force (Pitso) argued that military subculture hinders condom use by instilling a false sense of daring and invincibility.

Session 6. Barriers to condom use: comparative analyses
A study of regional variations and cross country determinants of condom use among men and women in twenty sub-Saharan African countries (Amouzou) found relatively low levels of condom use in each country, with less use reported by women than men. Condom users were individuals not in union, living in urban areas, comparatively educated, and with knowledge of condom efficacy.

Session 7. Personal/"cultural" barriers to condom use
The first paper in this session (UNFPA) presented both a compilation of myths, misperceptions and fears that hinder access to and use of condoms, and an account of strategies (provider-related, product-related, and consumer-related) to overcome such myths, misperceptions and fears. The remaining five papers presented case studies from Botswana, Ghana, Tanzania, and Malawi. Parallels might be drawn between the Ghanaian paper (Poku), which revealed how young men responded equivocally to the fear of AIDS, and the paper presented earlier on the Botswanan military in Session 5. Themes running through the papers included the enormous barriers to condom use within marriage and when fertility is prized, and the suspicion with which condom advocacy is greeted. The papers formed a valuable counterpart to those of Session 4.

Session 8. Institutional barriers to condom use
Supply-side considerations are a crucial part of the equation. An account of donor support (Chaya) revealed a large gap between estimates of condoms needed and condoms effectively used. Donor support has increased little over the past decade and suffers from poor coordination and management strategies. An Indian case study (Goyal and Khanna) revealed many deficiencies and inefficiencies in the programme of free condom distribution, leading to waste.

Session 9. Technical issues
Continuing efforts to improve the product can only increase use. Trials of non-latex condoms in Thailand and South Africa (Niruthisard et al.) provide useful baseline data on slippage and breakage as well as demonstrate the acceptability of the non-latex condom, at least in the former site. In the seminar's only paper on the female condom (Rakgoasi), awareness was found to be high in a low-income urban setting in Botswana, and attitudes were found to be positive. Use, however, is rare.

Session 10. What do we know? What don't we know?
The final afternoon of the seminar was devoted to discussion of the implications of the seminar papers for interventions and for further research.

Implications for interventions
Interventions to reduce stigmatization of condom use are greatly needed both as population-wide initiatives, especially among married people, and as programmes of information and services targeted at high-risk groups. Interventions to improve the correctness and consistency of condom use are high priority as are ones to improve supply and access, the latter encompassing both physical and logistical factors as well as psychosocial barriers. Integration of condom promotion into related services such as STI testing and treatment, voluntary counseling and testing for HIV, and into family-planning service provision, are other ways of increasing use. The meeting was encouraged by the finding that although overall levels of condom use are still low in most countries, use is increasing among high-risk groups (unmarried people, people with more than one sexual partner, young people). Interventions to increase use are useful as part of a comprehensive strategy to improve prevention of HIV/STI infections. Other components of a comprehensive approach include interventions to delay sexual debut (relevant only for young people) and to reduce the proportion of people who have multiple partners (relevant for all ages).

Implications for further research
Measurement issues abound. The measurement of actual condom use, rather than the respondent's categorization of her or his use as consistent or inconsistent (or never), is urgently needed although by no means simple since information is needed about each of a number of coital acts. HIV prevalence is best estimated at the population level through representative sample surveys rather than through examinations of special groups such as pregnant women. Knowledge of HIV/AIDS should be distinguished from awareness of HIV/AIDS. Unmet need for the condom for HIV and STI prevention requires a different algorithm from that used for pregnancy prevention. More detailed information is needed on the exposure of young people to HIV information both within and outside the school setting, and on the sexual activity of young people not in cohabiting relationships. An overriding issue is whether such measurement issues can be addressed adequately through the vehicle of established surveys such as the DHS and the CDC Reproductive Health Surveys, or if the HIV prevention community needs its own independent sample survey that also collects bloods.

Gigi Santow

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