Condom Programming For HIV Prevention
PREVENTING HIV, PROMOTING REPRODUCTIVE HEALTHCONDOM PROGRAMMING FOR HIV PREVENTIONAN OPERATIONS MANUAL FOR PROGRAMME MANAGERS 2005CONDOM PROGRAMMINGFOR HIV PREVENTIONAN OPERATIONS MANUAL FORPROGRAMME MANAGERSThe United NationsPopulation Fund220 East 42nd StreetNew York, NY 10017, USAISBN 0-89714-733-2
The United NationsPopulation Fund220 East 42nd StreetNew York, NY 10017, USAwww.unfpa.orgPHOTO CREDITSFront cover UNFPA/Ghana Field OfficeDepartment of ReproductiveHealth and ResearchWorld Health Organization1211 Geneva 27Switzerlandwww.who.intStep 1, page 6 Sarath Perera, Sri LankaStep 2, page 20 Viviane Moos, BrazilStep 3, page 32 P. Delargy, Sierra LeoneStep 4, page 46 UNFPA/Bill Ryan, AfghanistanPATH1455 NW Leary WaySeattle, WA 98107, USAwww.path.orgStep 5, page 54 L. Gubb, EthiopiaStep 6, page 60 WHO/J. Kohr, IndonesiaStep 7, page 74 H. Anenden, Africa
CONDOM PROGRAMMINGFOR HIV PREVENTIONAN OPERATIONS MANUAL FORPROGRAMME MANAGERS
ACKNOWLEDGEMENTSii
acknowledgementsThis document was prepared by PATH staff,including Patricia S. Coffey, Adrienne Kols,Maggie Kilbourne-Brook, and Clea Finkle,with the guidance of Jacqueline Sherris.Jack Kirshbaum edited the document withproduction assistance from Jennifer Fox andScott Brown. Information pertaining to Step 3 wasdeveloped with John Snow, Inc. (Raja Rao, leadauthor). Bongs Lainjo coordinated the project forUNFPA, where Kebedech Ambaye, Sylvie Cohen,Lynn Collins, Andre DeClerq, Lindsay Edouard,Anne Fabiani, Suman Mehta, Luca Monoja, andJagdish Upadhyay all provided helpful suggestionsand guidance. Thanks also to Maggie Usher-Pateland her colleagues at WHO and WHO/RHR fortheir review and comments.This document was pretested in India andKenya. The India pretest was organised andconducted by staff at the PATH country office,including Madhu Krishna, K.A. Balaji, Divya Jolly,and Megha Rathi, who worked in association withUNFPA-India representative François Farah andstaff members Dinesh Agarwal and Sachi Grover.Thanks to all the participants who offered theirtime and expertise, including representatives ofAIDS Awareness Group; All India Institute ofMedical Sciences; Family Health International;Family Planning Association of India; Governmentof India, Ministry of Health, Department of FamilyPlanning; Hindustan Latex Limited; IndianMedical Association; Parivar Swastya Sansthan;Population Services International; States AIDSControl Society, Delhi Branch; United StatesAgency for International Development; and WorldHealth Organization, India.The pretesting in Kenya was organised andconducted by staff at the PATH country office,including Irene Chami, Rufus Eshuchi, and RikkaTransgrud, working in association with FabiamByomuhangi and Ibrahim Sambuli of UNFPAKenya. Thanks to all the participants who offeredtheir time and expertise, including representativesof AMKENI Project; Condom Working Group,Ministry of Health; Department of ReproductiveHealth, Ministry of Health; Deutsche StiftungWeltbevölkung; Family Health International,Gesellschaft für Technische Zusammenarbeit; JohnSnow, Inc.; Maendeleo ya WanawakeOrganization; Marie Stopes International;National AIDS Control and STI Program;National Council for Population andDevelopment; and Neno Trust.iii
EXECUTIVE SUMMARYCondoms play a special role in combatingthe spread of HIV/AIDS because they arepresently the only devices that protectagainst sexually transmitted HIV.However, high costs to users, limitedavailability and accessibility, and negativeperceptions of condoms have created a gapbetween the number of condoms distributed andthe amount needed for populations to protectthemselves from HIV/STIs. Improved condomprogramming can help close the gap in condomsupply and use, and reduce the spread of HIV.The goal of condom programming is to ensurethat sexually active persons at risk of HIV/STIs areivmotivated to use condoms, have easy access toquality condoms, and can use them consistentlyand correctly. It addresses the supply of anddemand for condoms as well as the political,sociocultural, and economic environment. Thismanual outlines a seven-step process to improvethe effectiveness of existing condom programmesor to create a new condom programme. It isdesigned to give managers practical and specificadvice on condom programming.STEP 1. UNDERSTAND CONDOM CLIENTS AND THE ENVIRONMENT.In order to decide which client groups to target,managers must investigate potential client groups,
executive summarytheir risk of HIV infection, and the barriersdiscouraging them from using condoms. Acondom needs assessment gathers epidemiological,sociocultural, and behavioural information onpotential client groups and on the broadersociocultural and political environment.STEP 2. ASSESS PROGRAMME AND CREATE ACTION PLAN.A small staff team can conduct a rapid assessmentof a condom programme’s existing capabilities,including the supply and distribution of condoms;providers’ attitudes, knowledge, and skills;organisational support; service quality; andcondom promotion. Based on this informationand the needs assessment conducted in Step 1,managers can decide which issues—includingbarriers to condom use, adverse circumstances inthe environment, and programme weaknesses—must be addressed for condom use to rise andsubsequently create an action plan.STEP 3. PROCURE HIGH-QUALITY CONDOMS AND MANAGE THE PIPELINE.In order to maintain a reliable and consistentsupply of quality condoms, managers shouldreview and strengthen every element of thelogistics system, including data collection aboutdistribution and stock levels, product selection,forecasting condom needs, procurement, inventorymanagement, storage and transportation, andresupply distribution outlets.STEP 4. EXPAND DISTRIBUTION SYSTEMS.Managers can increase access to condoms andreach new client groups by using multipledistribution channels, increasing the number andtypes of outlets supplying condoms, and matchingthose outlets to clients’ needs. Potentialdistribution channels include commercial sales,social marketing, community-based distribution,and workplace promotion as well as the healthcare system. Using nontraditional outlets andchanging policies and service practices at healthfacilities to make them condom-friendly canexpand access to condoms.STEP 5. PROMOTE CONDOMS AT DISTRIBUTION POINTS.Managers should provide individual clientcounselling at condom distribution points—whether health facilities, retail shops, ornontraditional outlets—and, where this is notpossible, display and distribute educationalmaterials, such as posters and leaflets, instead togive condom clients essential information on howto use condoms correctly. To improve counselling,there is a need to train providers and focussupervision on condom service delivery.STEP 6. PROMOTE CONDOMS AT THE COMMUNITY, DISTRICT,AND NATIONAL LEVELS.Behaviour change communication—including peereducation, community education, school-basededucation, and mass media campaigns—canincrease knowledge, shape attitudes, and changebehaviours among potential condom clients andthroughout the broader community. Condompromotion efforts can extend their reach byworking with STI, HIV prevention, reproductivehealth, and refugee health programmes. They alsoneed to create a supportive political andsociocultural environment; raise awareness ofHIV/AIDS; place condom programming on thepolitical agenda; and make condom promotionsocially acceptable via advocacy to political,religious, community, and business leaders.STEP 7. MONITOR PROGRAMME PROGRESS AND EVALUATE OUTCOMES.Managers need to make sure monitoring andevaluation systems include key condom indicatorsso they can detect and fix problems, assessprogramme performance, and decide whichactivities to expand or stop. A completemonitoring and evaluation system measures inputs(the number of people trained in condomcounselling and distribution), outputs (theavailability and quality of condoms), outcomes(changes in condom use and sexual behaviour),and impacts (changes in HIV and STI rates).v
ACRONYMSAIDSacquired immunodeficiency syndromeBCCbehaviour change communicationCBDcommunity-based distributionHIVhuman immunodeficiency virusIDPinternally displaced personIPPFInternational Planned Parenthood FederationJSIJohn Snow, Inc.LMISlogistics management information systemNGOnongovernmental organisationPSIPopulation Services InternationalSTIsexually transmitted infectionUNAIDSJoint United Nations Programme on HIV/AIDSUNFPAUnited Nations Population FundUSAIDUnited States Agency for International DevelopmentVCTvoluntary counselling and testingWHOWorld Health Organizationvi
Table of ContentsiiivACKNOWLEDGEMENTSEXECUTIVE SUMMARY1INTRODUCTION6STEP 1. UNDERSTAND CONDOM CLIENTSAND THE ENVIRONMENTIdentify potential client groupsDecide which client groups to targetIdentify barriers that discourage condom useGather information on clients and environmentwith a condom needs assessmentAnalyse the results20STEP 2. ASSESS PROGRAMME AND CREATEACTION PLANOrganise an assessment ofprogramme capabilitiesAssess supply and distribution of condomsAssess providers’ attitudes, knowledge, and skillsAssess organisational support forcondom servicesAssess quality of servicesAssess condom promotion in the communityand to its influential membersDevelop an action plan for condomprogramming3246STEP 3. PROCURE HIGH-QUALITYCONDOMS AND MANAGE THE PIPELINESelect products that meet clients’ needsCollect and report essential dataForecast condom needs in the way that bestfits the programmeProcure condoms according to nationaland international standards and specificationsManage inventory, storage, andtransportation systemsEstablish reliable systems to resupplydistribution outletsSTEP 4. EXPAND DISTRIBUTION SYSTEMSMatch distribution channels and outletsto clients’ needsUse multiple distribution channels andnontraditional outletsEnsure easy access to condoms at health facilities54STEP 5. PROMOTE CONDOMS ATDISTRIBUTION POINTSMake confidential condom counsellingavailable to clientsTrain providersFocus supervision on condom service deliveryEncourage partner communication andparticipation in counsellingDisplay and distribute educational materials60STEP 6. PROMOTE CONDOMSAT THE COMMUNITY, DISTRICT,AND NATIONAL LEVELSUse behaviour change communicationto promote condom useTailor condom programming tospecific client groupsLink with other HIV-prevention andreproductive health programmesAdvocate for a supportive politicaland sociocultural environment74STEP 7. MONITOR PROGRAMMEPROGRESS AND EVALUATE OUTCOMESMeasure programme performanceand make improvementsIntegrate condom indicators into themonitoring and evaluation systemCreate an evaluation plan84RESOURCES87APPENDIXFact Sheets:Female CondomsMale CondomsProtecting Against Both HIV and PregnancyGender and Condom Programmingvii
viii
FIGURES, TABLES, AND WORKSHEETSWORKSHEETSFIGURES1.Elements of condom programming22.Seven steps for condom programmingfor HIV prevention43.Condom programming strategy forHIV epidemic levels114.Areas for assessment215.Developing an action plan306.Logistics cycle337.Forecasting for different stages of the epidemic368.Inventory and storage procedures429.Steps in planning health worker training5810. Steps to develop a behaviour changecommunication strategy6211. Level of effort for each type of evaluation7512. Steps in developing an evaluation plan831.Determine which client groups to target122.a. Compile information on targeted client groupsb. Key issues for targeted client groups16173.a. Compile information on environmentb. Key issues in environment18194.a. Condom supply and distributionb. Action items for condom supplyand distribution23a. Attitudes, knowledge, and skillsb. Action items for providers’ attitudes,knowledge, and skills246.a. Organisational supportb. Action Items for Organisational Support26277.a. Quality of servicesb. Action items for quality of service27288.a. Condom promotionb. Action items for condom promotion29299.List specific condom distributionchannels and outlets495.2425TABLES1.Appropriate condom outlets forvarious client groups48Strengths and weaknesses of condomdistribution channels51Tailoring behaviour change communicationto specific audiences64Obstacles to integrating condomprogramming into reproductive health servicesand possible solutions69Data sources and time frame for monitoringand evaluation system776.Output indicators for condom programming787.Outcome indicators for condom programming808.Impact indicators for condom programming822.3.4.5.ix
1.INTRODUCTION
i. introductionSLOWING THE HIV/AIDS PANDEMICSince the early 1980s, more than 60 millionpeople have been infected with humanimmunodeficiency virus (HIV), andmore than 20 million people have diedfrom the resulting disease, acquiredimmunodeficiency syndrome (AIDS).There were an estimated 5 million new infectionsin 2003 alone—the vast majority in developingcountries (Joint United Nations Programme onHIV/AIDS [UNAIDS], Report on the GlobalHIV/AIDS Epidemic 2002. Geneva: UNAIDS,2002). Of the 45 million new HIV infectionsprojected to occur between now and 2010, twothirds could be prevented by strengthening andbroadening prevention strategies ((Stover J et al.,“Can we reverse the HIV/AIDS pandemic with anexpanded response?” Lancet 2002;360:73–77).HIV has four major modes of transmission: Unprotected sexual intercourse with aninfected person; Transfusions of infected blood; Transmission from mother to child duringpregnancy, labour, delivery, or breastfeeding;and Injections with contaminated needles.Therefore, to combat the spread of HIV,prevention programmes must use a combinationof strategies. Promoting safer sexual behaviours,increasing condom use, diagnosing and treatingsexually transmitted infections (STIs), and offeringvoluntary counselling and testing (VCT) all helplimit transmission through unprotected sexualintercourse. Ensuring the safety of the bloodsupply prevents transmission through bloodtransfusions. Offering VCT and condoms topregnant women and their partners, treatingpregnant women with short courses ofantiretroviral drugs, using safe delivery practices,and counselling new mothers on infant feedingoptions can prevent HIV infection in pregnantwomen, mothers, and their newborns.Encouraging sterile injections, promoting safer sexpractices, and offering drug abuse treatment helpsminimise transmission among injecting drug users.In many areas, however, HIV is primarily spreadthrough unprotected sexual intercourse, so safersexual practices are key to controlling theepidemic. To reduce the sexual transmission ofHIV, many programmes follow a three-prongedapproach that encourages abstinence, faithfulnessto a single sexual partner, and condom use.Condoms play a special role because they arecurrently the only devices that protect againstsexually transmitted HIV. Consistent and correct1
i. introductioncondom use reduces the risk of heterosexualtransmission of HIV by about 80 percent (Weller Sand Davis K, “Condom effectiveness in reducingheterosexual HIV transmission.” CochraneDatabase of Systematic Reviews, 2001)—and alsoprotects against other STIs which may contributeto HIV transmission. Active promotion and use ofmale condoms has been proven to slow the spreadof HIV, and the promotion of female condoms hasincreased the number of protected sex acts.Because male and female condoms preventpregnancy as well as infection, they offer peoplethe convenience of dual protection. Condomuse can also help fulfil the unmet need forcontraception in developing countries, where morethan 100 million married and some 8 millionunmarried women of reproductive age wantto space or limit births, but lack access tocontraceptive methods (Ross J and Winfrey W,“Unmet need for contraception in the developingworld and the Former Soviet Union: an updatedestimate.” International Family PlanningPerspectives 2002;28:138–143).Target specific client groups.Identify barriers to accessand use.Given its importance in both preventing thesexual transmission of disease and protectingagainst unwanted pregnancy, condomprogramming is an essential part of reproductivehealth services for both men and women.Policymakers and programmers should considerhow best to use condom programming tocomplement and reinforce the full range ofreproductive health interventions, including STIservices, HIV prevention, family planning, andmaternal and child health care.ELEMENTS OF CONDOM PROGRAMMINGCondom programming is a strategic approach toensure that sexually active persons at risk ofHIV/STIs are motivated to use condoms, haveaccess to quality condoms, and can use themconsistently and correctly. Thus condomprogramming must address both the supply of anddemand for good quality condoms (see Figure 1)as well as the environment, which is the criticaloperating framework through which access to anduse of condoms is ensured.Select products that appealto clients and meet their needs.Forecast condom needs.Procure high-quality condoms.Use counselling and educationalmaterials to promote condomsat distribution points.Build community, social,and political support forcondom use.Figure 1. Elements of condom programming.2Manage inventory and useaccepted standards to storeand transport condoms.Distribute condoms throughmultiple channelsand outlets.
i. introductionOn the supply side, condom programmingmust select products that appeal to clients,forecast condom needs, procure sufficientquantities of high-quality male and femalecondoms, manage inventories, and distributecondoms—all with the goal of giving clients easyand confidential access to affordable condomswhen and where they need them.On the demand side, condom programmingmust assess the needs of different user groups,identify and remove barriers to condom access anduse (such as myths, perceptions, dislikes, andfears), promote consistent and correct condom useat service-delivery outlets and in the largercommunity, and build support for condom usewithin the broader sociocultural environment.Here the goal is to motivate women, men, andyouth who are at risk of HIV to use condoms.The surrounding political, sociocultural, andeconomic environment is critical to the success ofthese efforts. Social norms, institutional capacity,service accessibility, and public policy all have animpact on individual choices, gender roles, and theunderstanding of sexuality and disease. Limitedresources and infrastructure, including healthservices, may constrain efforts to promotecondoms. Therefore condom programming alsomust work towards an environment that supportsthe goal of safe, responsible, and consensualsexual relations and programme activities designedto reach that goal.countries. In sub-Saharan Africa, for example, the724 million condoms distributed by donoragencies and regional country governments in1999 amounted to less than 5 condoms annuallyper man aged 15 to 59 years (World Bank,Confronting AIDS: Public Priorities in a GlobalEpidemic. Washington, D.C.: World Bank, 1997).A similar supply gap exists for female condoms.Although the current annual global market for thefemale condom is about 10 million units, averageannual donor support for the female condom inthe developing world ranged from none to justover 100,000 condoms between 1996 and 2000(excluding supplies for well-developed femalecondom programmes in Ghana, South Africa,Uganda, and Zimbabwe) (Gardner R, BlackburnR, and Upadhyay U, “Closing the condom gap.”Population Reports, Series H: Barrier Methods1999:1–36).Production capacity is not responsible for thisgap. Condom manufacturing capacity isunderutilised and could expand greatly beforereaching its limit. Rather, high costs to users,limited availability and accessibility, and negativeperceptions of condoms all contribute to the gap.Many programmes do not reach potential userswith preventive messages that help them to changetheir behaviour.THE CONDOM GAPAccording to the Joint United Nations Programmeon AI
logistics system, including data collection about distribution and stock levels, product selection, forecasting condom needs, procurement, inventory management, storage and transportation, and resupply distribution outlets. STEP 4. EXPAND DISTRIBUTION SYSTEMS. Managers can increase access to condoms and reach new client groups by using multiple
3 The Male Latex Condom ΠFact Sheet 1 The condom A male condom is a sheath worn on the erect penis to prevent the exchange of body fluids during sexual intercourse.
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