PRB

(March 2003) Although women make up almost half of all people infected with HIV worldwide and 58 percent in sub-Saharan Africa,¹ they have limited options for preventing infection. Women are biologically more vulnerable to transmission from an infected partner than men are.² More important, economic, social, and cultural disempowerment means that the current HIV prevention strategies of abstinence, monogamy, condom use, fewer partners, and treatment of sexually transmitted infections (STIs) are not feasible for many women, since they often lack the ability to negotiate safe sex.³ There is, therefore, an urgent need for HIV prevention strategies that give women greater control. The female condom is the only female-controlled safe-sex method available. While this method is effective and relatively well-accepted by women, its usefulness is limited by cost, men’s negative attitudes, its contraceptive properties, and practical aspects of its use.

The female condom is a lubricated polyurethane sheath with a flexible ring on each end. One ring covers the cervix like a diaphragm; the other remains outside, partly covering the labia. More than 70 countries have approved its use,⁴ including the United States in 1993,⁵ Zimbabwe in 1996,⁶ and Ghana in 2000.⁷

The Condom’s Efficacy and Effectiveness

Hailed as the first barrier contraceptive for women that protects against STIs, the female condom won initial approval despite a relatively high pregnancy rate among users and with limited data on its actual effectiveness against STIs.⁸ However, evidence of its effectiveness has since accumulated.

As a contraceptive, the female condom compares favorably with other barrier methods. A Chinese study that compared the contraceptive efficacy of the female condom with the male condom showed similar pregnancy rates (1.06 and 1.69 pregnancies per 100 women, respectively, over six months). Discontinuation rates were higher for the female condom than for the male condom, however.⁹ During perfect use of the female condom, pregnancy rates were 2.6 in the United States and 9.5 in Latin America. These results are in the same range as other barrier methods.¹⁰ Other evidence from the United States suggests that the contraceptive efficacy of the female condom during typical use is similar to that of the diaphragm, the sponge, and the cervical cap.¹¹

Evidence suggests that the effectiveness of female condoms against STIs at a population level depends on existing levels of male condom use and on people’s willingness to use the female condom. A U.S. study found that the female condom effectively prevented recurrent vaginal trichomoniasis.¹² At the same time, introduction of the female condom on Kenyan plantations did not reduce rates of cervical gonorrhoea, chlamydia, and vaginal trichomoniasis compared with promotion of the male condom alone.¹³ Male and female condom use in this group was hindered by male partner objections, suspicion of the study and the devices, and bias against condoms by clinic service providers.¹⁴ In contrast, there was a 24 percent reduction in the rate of new STIs in groups of Thai sex workers who were given the choice of using either the male or female condom, compared with groups offered only the male condom.¹⁵

Acceptability and Use

There have been many studies of the use of the female condom in developing countries. Many have involved commercial sex workers who generally accept the device more quickly than other women.¹⁶ Most studies have shown high or moderate acceptability among sex workers, including those in China,¹⁷ Costa Rica,¹⁸ Côte d’Ivoire,¹⁹ Thailand,²⁰ and Zimbabwe.²¹ But these studies also revealed a number of barriers to the use of the female condom, including clients’ distrust of unfamiliar methods, inconvenience, insertion difficulties, discomfort or pain from the inner ring, and itching.

While many of these women said they liked the female condom and would recommend it to others, they still preferred to use the male condom for sex work.²² This suggests that the female condom may be a useful back-up method for commercial sex workers when men refuse to use the male condom.

Studies among women and heterosexual couples in China,²³ Kenya,²⁴ South Africa,²⁵ and Zambia²⁶ also showed relatively high levels of acceptability. Users often overcame initial problems with the female condom after several uses. In fact, women in Kenya, and both men and women in China, found that the device made sexual intercourse pleasurable. However, there was some resistance to its use, particularly in South Africa,²⁷ for a variety of reasons, including appearance, difficulties concerning its use, reluctance among male partners, over-lubrication and messiness, concern that the device is too large, and reduced sensation.

Women who have experience with the male condom or who receive more intensive training with the female condom generally find the device easier to use. Research in Zambia showed that the addition of female condoms with counseling on the barrier method mix could reduce unprotected sex among couples at high risk of HIV infection.²⁸

Marketing Strategies

Social marketing has been used widely in the promotion of the male condom in developing countries and this strategy is now being applied to the female condom. A mass-marketing campaign for the female condom in Lusaka, Zambia, raised awareness of this method, but its use is still much lower than that of the male condom. The female condom is likely to be most important for people who are unable or unwilling to use the male condom.²⁹

Higher Cost Leads to Reuse

One of the major barriers to widespread use of the female condom is the cost. The female condom costs around 20 times more to produce than the male condom.³⁰ It may, however, be possible to reuse a female condom if it is cleaned and relubricated correctly after each use. There is evidence that women in Zimbabwe, particularly commercial sex workers, already do this out of economic necessity.³¹ Some of the formal research on this issue comes from South Africa. A study of 150 women in Johannesburg showed that 83 percent would be willing to reuse the female condom. They found that the steps involved in reusing the device were easy to perform and acceptable.³² U.S. data suggest that structural integrity of the female condom remains intact after a single use and cleaning.³³ While laboratory tests in South Africa showed that washing, drying, and relubricating the female condom up to 10 times led to decline in its structural integrity for some washing procedures,³⁴ another South African study detected no deterioration after eight uses when evaluated against the U.S. Food and Drug Administration’s minimum standards for new female condoms.³⁵

The World Health Organization (WHO) has held two expert consultations on reuse of these condoms in response to the reality that the practice is already common among women in developing countries.³⁶ Although WHO continues to recommend the use of a new female condom for each act of intercourse, the organization has produced a draft protocol for safe handling and preparation of the device for reuse, in the interests of harm reduction.

Problems and Prospects

In a study to assess the cost-effectiveness of the female condom in preventing transmission of HIV and other STIs in sub-Saharan Africa, researchers modeled the impact of a program that would distribute female condoms to commercial sex workers in Mpumulanga Province, South Africa. Researchers estimated the number of HIV, syphilis, and gonorrhea infections that use of the female condom would prevent. The study, which also looked at associated costs and the use of both types of condoms, concluded that well-designed female condom programs would likely be highly cost-effective.³⁷ Other research underlined the importance of addressing sources of resistance among reproductive health care providers and of enhancing their skills in teaching female condom negotiation strategies and use.³⁸

There are, however, problems with the female condom. A series of studies in southwest Uganda found that although women like vaginal products because they feel they have greater control over their sexual and reproductive health, their use often involves some negotiation with male partners.³⁹ Men may also be ambivalent about female ownership of these products.⁴⁰ While the female condom is seen as an improvement on the male condom, the device has limited value because of the need to agree to its use before sex. There is, therefore, a clear demand for a vaginal product that protects women from HIV and other STIs and can be used without the male sex partner’s knowledge. Because they also function as contraceptives, male and female condoms are problematic for couples who want to have children.⁴¹

These issues are driving the effort to produce vaginal microbicides — including noncontraceptive ones — to reduce the risks of contracting HIV and other STIs. As the first product available to women that protects against STIs, the female condom is an important component of any comprehensive HIV prevention toolkit. Its limitations underscore the need for a method that women can use without the knowledge or agreement of men, however. The development of a cheap, safe, and effective vaginal microbicide would likely have a major impact on the lives of women, 1.2 million of whom died of AIDS last year.⁴²

Heidi Brown is a health communications specialist and freelance writer on international health.

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