The Female Condom

	Source: USAID

The Female Condom Is Safe and Effective

On March 10, 2009, the Food and Drug Administration approved the second generation of the female condom (FC2). Made of nitrile (synthetic latex), the design and appearance of the FC2 are essentially the same as the previous version’s. The World Health Organization concluded in 2006 that the FC2 was comparable to the first generation of the female condom (distributed under the brand names Reality and Femidom) in both safety and effectiveness, and when used consistently and correctly, female condoms are comparable to the effectiveness of male condoms.

Female Condom Promotion Is a Cost Effective HIV Prevention Intervention

Promoting the female condom is a cost-effective intervention, especially in relation to the cost of HIV treatment and other prevention interventions and when the use of male condoms is not a viable option. Two different mathematical modeling studies predicted the cost savings of female condom promotion and concluded that expanded female condom promotion is likely to be a highly cost-effective intervention. One model predicted a cost-savings if the female condom were targeted to women with at least one casual partner and used in 12 percent of sexual encounters.¹ The other model predicted that the expansion of female condom distribution could avert new HIV infections; this would lower the cost of treatment thereby making responses to both generalized and concentrated epidemics less expensive.² The use of a new material for the production of the FC2 reduced the cost of the female condom by one-third, and savings will be even greater as sales increase due to economies of scale.

The high cost of the female condom relative to the male condom was previously viewed as one of the major barriers to its widespread distribution. The recent reduction in the cost of the FC2 has had some impact on distribution, but it is not until the volume of FC2 distribution markedly increases that the price will drop significantly. Another way to reduce the cost of female condoms is through greater competition. Two female condoms are currently in various stages of the approval process and will be available in the near future. The Phase III pivotal clinical trials of the Women’s Condom developed by PATH, which is manufactured in China, began in 2011 with support from The National Institute for Child Health and Human Development/National Institutes for Health. The V’Amour/Protectiv, a latex female condom produced by Medtech in India, is now available in some countries and will be resubmitted for pre-qualification approval by the World Health Organization. It is anticipated that both of these products will be less expensive than the FC2.

Female Condom Can Increase Protected Sex

The female condom is the only female-initiated method available that can be worn by women for protection against both unintended pregnancy and sexually transmitted infections. Female condom use can also be initiated by men. A growing body of evidence shows that effective female condom promotion by both women and men can increase the proportion of protected sex acts.^{3, 4, 5}

Qualitative studies have shown that some women are able to use the female condom in situations where they cannot negotiate male condom use,⁵ and many users alternate between male and female condoms. Because the female condom can be inserted before sex and is not dependent on an erect penis, it may be particularly useful for women whose partners are under the influence of drugs or alcohol.

Increased Choice Equals Increased Use

Studies conducted in a variety of contexts show that the female condom is widely acceptable and a realistic alternative to the male condom.⁶ Lessons learned from many years of past experience in the family planning field illustrate how increasing method choice can increase uptake and use of contraceptives,^{5, 7} and there are indications that this is true in the case of condoms as well. One study found that providing a choice of condoms successfully increased acceptability.⁸

The Female Condom Is an Untapped Resource for HIV Prevention

Despite the potential of the female condom as a cost-effective HIV prevention intervention, efforts to promote the female condom have lagged since its development in 1993. Despite high rates of HIV infection among women globally, the number of female condoms distributed is only 1.6 percent of total condom distribution. There is an urgent need for leadership as well as adequate investments in female condom programming.⁹ Promotion of female condoms now may also help to pave the way for future female-initiated products, such as microbicides and new multi-purpose combination technologies. Legislation in the 2008 reauthorization of the U.S. President’s Emergency Plan for AIDS Relief specifically mandates the promotion of female condoms and analyses of the strategies used to promote both male and female condoms in the next report to Congress. To build upon this legislative mandate to endorse women-initiated means of protection against HIV/AIDS, the female condom should be promoted as a safe and effective HIV prevention intervention.

Considerations for Female Condom Programming

Social Marketing

Social marketing of male and female condoms can dramatically increase the number of condoms distributed in developing countries.⁷ Scaling up mass media campaigns and branding for the female condom is needed in order to increase awareness and uptake of this method. Promoting the female condom as something that can be used to increase sexual pleasure is one approach that has been successful in increasing its use.¹⁰ Acceptability and uptake of the female condom also may be increased if it is promoted as a method for dual protection against both unintended pregnancy and sexually transmitted infection, particularly in the context of hyperendemic and generalized epidemics where the majority of infections occur within regular partnerships. Identifying a target population is an important component of social marketing. However, targeting the female condom only to highly stigmatized groups, such as sex workers, may further stigmatize the method and create additional barriers to its use. Therefore, targeting strategies should be carefully considered.

Provide Comprehensive Sexual Risk Reduction Counseling

Female condom promotion should be delivered within the context of comprehensive condom programming. Programming should also include sexual risk reduction counseling that incorporates a wide range of prevention messages, including messages about partner reduction and information about biomedical interventions, such as male circumcision. In order for behavior change communication interventions to achieve maximum impact, people must have access to information about all of their options for prevention, including the female condom.

Include Men

One of the characteristics of the female condom is that it cannot be used covertly by women. Nevertheless, the availability of a method that can be used discreetly, such as a microbicide, is still a couple of years away.¹¹ Therefore, it is essential that female condom promotion efforts also reach male partners, who are critical in the uptake and use of this method. In fact, some men may prefer female condoms over male condoms. Advantages include its larger and less restrictive size, the fact that it does not depend on a fully erect penis, that it can be inserted long before intercourse, and that it does not need to be removed immediately after ejaculation. The female condom is a method that can be initiated by both men and women and, therefore, should be promoted as such.

Integrate Female Condom Promotion into Other Program Areas

	Source: USAID

Integrating female condom promotion into other services, such as family planning; HIV counseling, testing, and treatment; circumcision, and prevention of mother-to-child transmission, can help to increase the demand for this method among potential users.

Train and Support Providers and Peer Educators

Training for service providers that is specifically focused on female condom promotion is urgently needed and currently one of the major barriers to effective promotion and/or use of this method. Programs must increase awareness about the method among service providers and also address provider attitudes that are critical to its acceptance among potential users. Counseling that includes a demonstration of how to insert the female condom as well as a discussion of effective strategies for negotiating female condom use is more likely to result in the adoption and correct use of this method. Also, providers and peer educators require the tools necessary to support successful female condom promotion, such as pelvic models and information, education, and communication materials produced in local languages.

Measure Progress

Indicators that disaggregate male and female condoms are crucial to monitoring the progress of efforts to promote the female condom. Disaggregating the female condom on population-based surveys, such as the DHS, is being done in some countries, and this practice needs to be widespread in order to measure the impact of female condom interventions. While the endpoint of female condom promotion and use is reduction in HIV transmission and unintended pregnancy, this may be difficult to measure.

Additional Readings

• “Saving Lives Now: Female Condoms and the Role of U.S. Foreign Aid,” Center for Health and Gender Equity, 2008. [PDF, 1.4MB]
• Featured Publications, Prevention Now! Campaign Website.
• “Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health,” Center for Health and Gender Equity, 2011. [PDF, 2.8MB]
• “Female Initiated HIV Prevention Methods: Joint Advocacy Statement,” United Nations Population Fund and Partners, 2010. [PDF, 1.7MB]
• “Towards a Unified Approach UNAIDS Inter-Agency Task Team on Comprehensive Condom Programming, United Nations Population Fund,” 2010. [PDF, 160KB]

References

1. Marseille E, Kahn JG, Billinghurst K, Saba J. “Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa,” Soc Sci Med, 2001; 52:135–48.
2. Dowdy DW, Sweat MD, Holtgrave DR. “Country-Wide Distribution of the Nitrile Female Condom (FC2) in Brazil and South Africa: A Cost-Effectiveness Analysis,” AIDS, 2006; 20(16):2091–8.
3. Shane B; Herdman C, Dahlquist K, Agarwal D, Ambaye Nigussie K, Blumenthal P, Deperthes B, Edouard L, Jackson H, Malunga G, Kraus S, Nyamukapa D, Schuller A, Spieler J. “The female condom: significant potential for STI and pregnancy prevention,” Outlook, 2006; 22(2).
4. Vijayakumar G, Mabude Z, Smit J, Beksinska M, Lurie M. “A Review of Female-Condom Effectiveness: Patterns of Use and Impact on Protected Sex Acts and STI Incidence,” Int J STD AIDS, 2006; 17(10):652–9.
5. Hatzell T, Feldblum PJ, Homan RK, Gmach RD. “The Female Condom: Is ‘Just as Good’ Good Enough?” Sexually Transmitted Diseases, 2003; 30 (5):440–442.
6. French PP, Latka M, Gollub EL, Rogers C, Hoover DR, Stein ZA. “Use-effectiveness of the female versus male condom in preventing sexually transmitted disease in women,” Sexually Transmitted Diseases, 2003; 30(5): 433–9.
7. Gray AL, Smit JA, Manzini N; Beksinska M. “Systematic review of contraceptive medicines ‘Does choice make a difference?’” RHRU, 2006.
8. Steiner MJ, Hylton-Kong T, Figuero, P, Hobbs MM, Bhets F, Smikle M, Tweedy K, Powell S, McNeil L, Brathwaite A. “Does a Choice of Condoms Impact Sexually Transmitted Infection Incidence? A Randomized, Controlled Trial,” Sexually Transmitted Diseases, 2006; 33 (1): .31–35.
9. Holden S. Failing Women, Withholding Protection, Oxfam Briefing Paper, Oxfam Int’l, 2008. Retrieved from: http://www.oxfam.ca/news-and-publications/publications-and-reports/failing-women-withholding-protection/file
10. Philpott A; Knerr W; Maher, D. “Promoting protection and pleasure: amplifying the effectiveness of barriers against sexually transmitted infections and pregnancy,” The Lancet, 2006; 368 1–4.
11. Karim QA, Karim SA, Frohlich JA, et al. “Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women,” Science, 2010.

September 2011

The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.