Condom
Programming
Toolkit
Draft – March 2009
Srdjan Stakic, EdD
UNFPA
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INTRODUCTION TO THE TOOLKIT
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PURPOSE OF THE MANUAL
AUDIENCE
FORMAT/CONTENT
WORKSHOP SIZE
WORKSHOP SCHEDULE
TEACHING AIDS
EVALUATION
NOTE ON THE PRINCIPLES OF ADULT LEARNING
AUTHORS
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CHAPTER I: COMPREHENSIVE CONDOM PROGRAMMING
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER II: MALE AND FEMALE ANATOMY
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER III: REPRODUCTIVE HEALTH
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER IV: BASICS ABOUT SEXUALLY TRANSMITTED INFECTIONS AND HIV
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER V: DUAL PROTECTION
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER VI: INTRODUCING THE MALE CONDOM
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER VII: INTRODUCING THE FEMALE CONDOM
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER VIII: REPRODUCTIVE HEALTH COMMODITY SECURITY
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER IX: RISK ASSESSMENT AND BEHAVIOUR CHANGE
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER X: ADDRESSING MYTHS, MISPERCEPTIONS AND FEARS AROUND CONDOMS
AND CONDOM USE
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OBJECTIVES
KEY POINTS
OVERVIEW
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CHAPTER XI: CONDOM NEGOTIATION TECHNIQUES
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OBJECTIVES
KEY POINTS
OVERVIEW
PRESENTATION SLIDES
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CHAPTER XII: OTHER HIV PREVENTION STRATEGIES AND INTERVENTIONS
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OBJECTIVES
KEY POINTS
OVERVIEW
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Introduction to the Toolkit
Purpose of the Manual
The purpose of this manual is to provide guidance to trainers
1. Who will serve as trainers of service providers in order to establish a large
cadre of professionals able to understand basic and advanced concepts of
male and female condom programming
2. Who will train, educate and counsel condom users or potential condom users
on how to users male and female condoms correctly and consistently
Audience
The primary audience of these tools are trainers in all regions of the world,
including physicians, nurses, NGO members, Ministry of Health representatives and
other relevant stakeholders. The assumption of the authors of this manual is that
audience members will have some previous understanding of medical and/or public
health concepts of HIV prevention and sexual and reproductive health promotion
and thus only basic information will be provided in this toolkit.
Format/Content
This training manual is apart of the Generic Training Package (GTP) –
applicable in all cultural, religious and geographic areas/regions. The
process of adapting of this GTP will be conducted independently after the
completion of these documents.
This training manual utilizes adult-learning techniques and seeks to draw
from the experiences of service providers to develop solutions to any
problems they encounter in promoting male and female condoms. It takes
into account the cultural reality of different regions and offers service
providers skills I think the manual would not be able to provide skills but:
provide information on… promoting condoms.
All the topics identified in this GTP comprise the full training package on
male and female condom promotion. The training package fulfils the
following dissemination objectives:
a. Each topic/section may stand on its own for training purposes with
references or links provided for any related material that may be
within other sections.
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b. Each section includes adequate age- and gender-balance in the
content of the material discussed reflecting the needs of both young
and mature men and women. This allows for greater adaptability of
the tools and wider use by service providers who work with various
populations.
Workshop Size
The recommended number of participants is 20 to 25 per workshop so that the
training may facilitate participation..
Workshop Schedule
The manual can be covered in full in five days or if necessary, trainers and
participants can adapt it as per the need of their program.
Teaching Aids
The manual includes all necessary teaching aids (case studies, exercises,
presentations, multimedia tools, etc.).
Evaluation
To evaluate the effectiveness of the workshop, trainers should ask participants to
take the same test before and after sessions. Questions to be given to participants
are included at the end of each session.
Note on the Principles of Adult Learning
Trainers who use this manual should follow the principles of adult learning. These
include1:
Adults learn best when they are actively involved in their own training and
when training builds on their own experiences and knowledge. As
participants in these workshops will be service providers, the assumption of
authors of this text is that they will carry with them a certain level of
knowledge and professional (and life) experience. Trainers should utilize
these in their work.
Adapted from: Reproductive Health Manual for Trainers of Community Health Workers.
(2003). Centre for Development and Population Activities and USAID. Available online at:
http://www.hrhresourcecenter.org/node/1419
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How you teach is as important as what you teach. The tools provided in this
manual should help you design your trainings in an informative and
interesting, attention-grabbing manner.
While lectures are sometimes necessary, research shows that they are not
the best way to teach. Adults learn best when training allows them to
discover their own solutions to problem. Thus, utilize discussion in large or
small groups and in pairs, exercises and other pedagogical methods that will
encourage participants to think and come up with their own answers to
various questions.
Adults learn best through doing. The next best way they learn is through both
seeing and hearing. As participants in these workshops will serve as trainers
themselves of the same subject, consider involving them in facilitating some
of the sessions.
Adults want to learn what they can apply immediately.
Given below are suggested methods:
o Use simple, appropriate, culturally, and religiously acceptable
terminology.
o Use games, discussion, case studies, demonstration, simulated
practice, question-and-answer sessions, brainstorming, etc.
o Move at a pace comfortable for the participants.
o Provide (positive) feedback to ensure a participatory teaching and
learning process.
Authors
Insert a note on the Interagency Group and the consultant.
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Chapter I: Comprehensive Condom Programming
Objectives
To define the Comprehensive Condom Programming (CCP) approach
To understand what role service providers play in CCP
Key Points
Comprehensive Condom Programming
Comprehensive condom programming is an approach used to create and
strengthen:
Leadership and coordination
Supply and commodities security
Access, demand and utilization
Support
It integrates various activities including male and female condom promotion,
communication for behaviour change, market research, segmentation of messages,
optimized use of entry points (in both reproductive health clinics and HIV
prevention venues), advocacy and coordinated management of supplies.2
The goal of CCP is to reduce the number of unprotected sex acts, leading to fewer
unintended pregnancy and sexually transmitted infections including HIV.
In other words, CCP seeks to develop strategies and programmes wherein every
sexually active person -- regardless of age, marital status, gender, sexual
orientation, economic situation, HIV status – has access to good quality condoms
when and where s/he needs them, is motivated to use males or female condoms as
appropriate and has the information and knowledge to use them consistently and
correctly.
CCP approaches may vary from country to country, depending on many factors.
Understanding your local epidemiology, distribution infrastructure, cultural context
and budgetary issues will be important for effective training.
CCP recognizes that both male and female condoms are essential for the prevention
of unintended pregnancy and STIs including HIV, known as dual protection. It
ensures that condoms are provided at many places -- not just in health centers and
Adapted from: Comprehensive condom programming: A strategic response to HIV/AIDS. (2008).
UNFPA: New York. Internet document, available at: http://www.unfpa.org/hiv/programming.htm
2
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pharmacies, but also in non-traditional distribution points such as hair salons,
barber shops, vending machines, night clubs, youth centres, etc.. It requires the
collaboration of the private and public sector, also leveraging the social marketing
sector to reach specific populations and create demand for male and female
condoms. And it requires a consistent and affordable supply to ensure that
individuals can access condoms whenever and wherever they are needed.
What role can service providers play in CCP?
As a service provider, you have a key role to play in CCP. You are the gatekeeper to
condom users and you also can play an important role to advocate to your leaders
for the implementation and continued momentum of CCP. Whilst service providers
may e seen as gate-keepers, this is to a very limited extent. Community leaders are the
ones largely play the gate-keeping role.
Importantly, your specific role is to raise awareness on STI/HIV and unintended
pregnancy risk, condom as a dual protection method, risk of HIV/STI, make goodquality condoms readily available, teach people how to use condoms consistently
and correctly, work to eradicate the social stigma associated with male and female
condoms, and advocate for the integration of condoms into other HIV prevention
and SRH programmes.
Talking about condoms is not always easy for potential condom users. We
recommend the following five actions to create an enabling environment:
Step 1. Create an interactive, client-friendly environment.
Step 2. Ensure that high-quality condoms are always available.
Step 3. Counsel users about correct and consistent condom use in a supportive
manner.
Step 4. Reach out to the community.
Step 5. Check progress.
Step-by-Step Strategic Approach to Comprehensive Condom
Programming
Steps in Strategic Comprehensive Condom Programming may vary from country to
country, depending on many factors, from the local epidemiology of STIs,
distribution infrastructure, cultural context to budgetary issues. However, the
process of designing and implementing a strategy has many common features,
which are described below.
Your government is using the CCP process to strengthen your country’s condom
?programmining. These are the steps that they may be following. Training service
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delivery providers like yourself falls under step 7, and your work with clients is a
part of step 8. However, you can also play a role in the other steps by advocating for
implementation and momentum around CCP
Step 1: Establish a National Condom Task Team (NCTT) Lets be consistent in the use
of terms. The RNA tool call this committee National Condom Support Team, NCST.
Step 2: Undertake a Situation Analysis
Step 3: Develop a Comprehensive and Integrated National Male/Female Condom
Strategy and cost each component
Step 4: Develop a 5 year Strategic Plan
Step 5: Develop a Commodity Security Plan
Step 6: Mobilize Resources
Step 7: Develop and implement a Human Resource capacity strengthening plan
Step 8: Develop a condom promotion plan to increase access and utilization
Step 9: Advocacy and Media
Step 10: Monitor programme implementation routinely and evaluate outcomes
Five Steps for Increasing Demand for and Supply of Condoms
To encourage people to use condoms, programmes need to raise awareness of
HIV/STI risks, make good-quality condoms readily available, teach people how to
use condoms correctly, work to eradicate the social stigma associated with
condoms, and advocate for HIV prevention and condom use in the community.3 The
following five-step process may be used to increase the demand for and supply of
condoms:
Step 1. Make the outlet client-friendly.
Step 2. Ensure that high-quality condoms are always available.
Step 3. Counsel clients about condoms.
Step 4. Reach out to the community.
Step 5. Check progress.
Condom Programming for HIV Prevention: A Manual for Service Providers. (2003). UNFPA, WHO &
PATH: New York
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Overview
Condom Programming4
I think the overview needs to come much earlier at the beginning of the chapter.
What is Condom Programming? Condom programming is an integrated approach
consisting of demand, supply and support functions that was created to expand
access and help prevent the spread of STIs, including HIV. To give the condom
higher visibility and impact, the World Heath Organization’s (WHO) Global
Programme on AIDS (GPA) developed and embraced comprehensive condom
programming in April 1988. Before then, the condom was generally viewed as an
unpopular, not-so-effective family planning method stigmatized because of its
association with sex outside of marriage. As a family planning device, providers did
not consider the condom a “modern” method and consequently relegated it to the
lowest rungs of the contraceptive ladder.
While negative attitudes are still prevalent today, condom programming is now
recognized as one of the most significant primary approaches in the fight against
HIV. According to the United Nations Population Fund (UNFPA), the agency within
the UNAIDS system responsible for condom programming: “Condoms are
universally recognized as one of the most effective ways to prevent HIV and other
sexually transmitted infections.” 5
Comprehensive condom programming and the provision of testing and conselling
services go together: they arise out of the basic logic of prevention which is: know
your status and take action. Routine testing and counselling (TC), which helps
identify HIV positive people who may need antiretroviral treatment, is a valuable
companion intervention that justifies condoms as a rational STI/HIV prevention
choice, even in stable sexual relationships. Successful condom promotion requires
easy access to TC. Why? Because healthcare personnel must be able to educate
couples regarding when to stop using condoms should they adopt a long-term
strategy of faithfulness to an uninfected partner. Without access to TC, couples in a
world affected by HIV/AIDS have no way of knowing whether, or how, to stop using
condoms and start childbearing with a clear conscience and free of fear. Please take
note that there have been a deliberate shift from emphasis on VCT to routine offer of
Testing and Counselling (TC). Most countries have taken up routine offer of TC as a
strategy for increasing the number of people to be tested for HIV.
Condom programming operates in the real world where STIs and HIV infections
occur. Comprehensive condom programming recognizes that the typical human life
Source: Friel, P. (23 September 2007 Draft). Condom Programming: An Intergral Part of HIV
Prevention and Treatment. UNFPA: In Press.
5 HIV Prevention Now, Programme Briefs, No. 6, Condom Programming for HIV Prevention, June
2002.
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cycle in diverse communities requires different tactics for different people at
different times. When working properly, condom programming involves a range of
activities that embrace political and financial issues as well as programmatic
(operational and managerial) priorities at all levels.
Political leadership: condom programming requires high-level support for an
integrated public health, i.e., evidence-based, approach based on STD epidemiology.
All too often, national authorities fail to recognize, and respond to the fact that
condom-related stigma casts a long shadow over their work. This adversely affects
even evidence-based and age-appropriate interventions for reproductive health and
disease prevention. Unwavering political leadership must confront stigma and
continually remind stakeholders that proper and consistent condom use can save
lives, protect families, ?strengthen the economy and help secure the future of the
community.
Financial support: donors and governments must realize that even the best
designed and politically-supported condom programmes will fail without adequate
and continuous long-term financial support. This factor profoundly affects every
other priority.
Programmatically responsive: access to, and use of, condoms helps protect a wide
range of young, middle-aged and older people in society. These include first-time
sexually-active youth, women engaging in intergenerational or transactional sex, sex
workers and their clients, men who have sex with men, injecting drug users and
their partners and discordant couples, including monogamous married women
whose husbands bring home infections, e.g., after working abroad. This is a complex
equation. Because condom programming must serve different socio-economic
geographic and cultural target audiences, it requires that different sectors and
agencies working in urban and rural areas mount a coordinated, adequately-funded
national response. Again, political leadership is needed to assure that integrated,
evidence-based approaches are supported and that stigma is countered with
wisdom and courage.
Step-by-Step Strategic Approach to Comprehensive Condom
Programming This section appears to be a repetition of what has
been explained above.
To be strategic, condom programming must:
Recognize complimentarity between male and female condoms;
Be integrated and optimise use of different entry points in RH and HIV
prevention settings;
Segment population including young people; and
Appropriately utilise public, social marketing and private sector mix.
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The goal of comprehensive condom programming should be to increase the number
of protected sex acts that will reduce incidence of unwanted pregnancy and STIs
including HIV.
Steps in Strategic Comprehensive Condom Programming may vary from country to
country, depending on many factors, from the local epidemiology of STIs,
distribution infrastructure, cultural context to budgetary issues. However, the
process of designing and implementing a strategy has many common features,
which are described below. A number of publications are available to guide you and
explain how this process has worked in various countries.
Step 1: Establish a National Condom Task Team (NCTT)
Step 2: Undertake a Situation Analysis
Step 3: Develop a Comprehensive and Integrated National Male/Female Condom
Strategy and cost each component
Step 4: Develop a 5 year Strategic Plan
Step 5: Develop a Commodity Security Plan
Step 6: Mobilize Resources
Step 7: Develop and implement a Human Resource capacity strengthening plan
Step 8: Develop a condom promotion plan to increase access and utilization
Step 9: Advocacy and Media
Step 10: Monitor programme implementation routinely and evaluate outcomes
Cost-effectiveness of the female condom6
Before talking about female condom research we need to introduce the female condom
and say what it is and its role in STI/HIV prevention.
Perhaps the most important new research to emerge about the female condom is
that it may be cost-effective to provide the female condom in reproductive health
programmes. Particularly in target groups that practise high-risk behaviours, female
condom programmes can even be cost-saving. Family Health International (FHI),
The Female Health Company (FHC), Health Strategies International (HSI),the
Institute of Health Policy Studies at the University of California, the London School
of Hygiene and Tropical Medicine, Population Services International (PSI) and
UNAIDS have all been engaged in research to measure the cost-effectiveness of
introducing the female condom into reproductive health programmes. The findings
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Source: The Female Condom: A guide for planning and programming. (2000). WHO & UNAIDS.
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from these various studies indicate that the female condom can be a cost-effective
addition to prevention programmes. This cost-effectiveness is maximized under the
following conditions:
Targeting in high-prevalence areas
Not surprisingly, the female condom becomes increasingly cost-effective and even
cost-saving as the level of risk of STIs and HIV/AIDS increases among users and
their partners. By targeting sex workers and other women and men with multiple
sexual partners, the female condom can be not only cost-effective but also costsaving to the health care system.
Providing the female condom in combination with the male condom
The purpose of introducing the female condom into national reproductive health
programmes is to increase the number of protected sexual acts, decrease the
incidence of STIs and HIV/AIDS and unintended pregnancy, and thus decrease the
associated costs. Because the female condom has a higher unit cost, the female
condom should be targeted at populations that already have ready access to the
male condom or are not able to use the male condom consistently. Shall we simplify
this? It is difficult to understand. By focusing on these groups, female condom use
increases the number of protected sexual acts without necessarily decreasing male
condom use.
Incremental increase in protection
The experience from family planning programmes over many years highlights the
importance of simply expanding people’s choice. The addition of contraceptive
methods to the options available to people produces incremental increases in
contraceptive prevalence. Similarly, the addition of the female condom to the
options for safer sexual behaviour has produced incremental increases in protected
sexual acts.
Planning strategically for the introduction of the female condom7
Before activities begin for the introduction of the female condom into a country or a
programme, it is important to design a comprehensive introduction strategy. In fact,
the first question that needs to be asked is whether there is a need to introduce the
female condom, or whether priority should be placed on improving the provision of
currently available methods. The above statement in my view could be misleading.
The only other available dual protection method is the male condom. I think the female
condom should be introduced anyway, even when the male condom programme is
working well, so as to widen choice. The male condom may not be able to address the
STI/HIV prevention needs for everybody, e.g. those with latex allergies, those whose
partners refuse to wear the male condom etc. Evidence from experiences with
contraceptive introduction demonstrates that the addition of a new method in itself
does not automatically lead to increased choice. Service delivery systems do not
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Source: The Female Condom: A guide for planning and programming. (2000). WHO & UNAIDS.
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always have the capability to provide a new method with the appropriate care.
Although small-scale studies and introductory trials of new methods usually offer
high-quality services, weaknesses in training, counselling, supervision and logistics
management often make it difficult to sustain quality services when the method is
introduced on a larger scale.
Factors such as confusion on the part of providers and consumers as well as failure
to take into account their beliefs, attitudes, concerns and experiences can also
counteract the potential that new methods have for expanding contraceptive
options for clients. Kindly explain what confusion this is, and where it could arise
from. Costs, side-effects, the manner in which clients are treated in clinics and many
other personal, cultural and socio-economic factors affect the demand for and
acceptability of a contraceptive.
In developing an introduction strategy it is important to think strategically, and see
the female condom as one of a range of methods that an individual or couple could
use to prevent pregnancy and/or STIs, including HIV.
In order to do this, programme managers must consider the needs of potential
users, the services and technologies currently available and the current capability of
the service delivery system, when planning female condom introduction activities.
Assessing and addressing all of these dimensions is essential to the success of
introductory activities. In addition, these issues cannot be seen in isolation, but must
be considered within a broader social context, including the sociocultural
environment, the broader reproductive health status and needs of individuals, and
the political and resource environments.
This strategic approach to introduction is described in more detail in WHO’s “A
guide for assessing strategies to broaden contraceptive choice and improve quality
of care”(see Section 8). In this approach, any country thinking about introducing any
contraceptive method should conduct a multi-faceted assessment of the situation
through a participatory process.
The steps in planning this process are outlined below.
1. Develop a national team to coordinate activities.
2. Organize a stakeholders’ meeting to put the female condom on the public
health agenda and gain a mandate for developing a strategic plan.
3. Assess user needs and service capabilities and currently available methods
and services. Outline the context for the introduction of the female condom.
4. Draft a strategic document. Use the document to obtain consensus from all
stakeholders.
5. Implement pilot intervention with monitoring and evaluation.
6. Feedback, revision and going to scale – expand programme on broader scale.
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Steps to introduce and integrate the female condom into
reproductive health programmes8
1. Strategy for integration. Develop a strategy on how best to integrate the
female condom into existing programme activities.
2. Programme costing.
3. Select the target audience(s). Determine potential populations for
promotion and subdivide them into different potential target audiences.
4. Gather information from the target audience. Assess the existing
perceptions of the female condom among the target group.
5. Advocacy with the community and consolidation of support. Meet with
the community to gain their support for the introduction of the female
condom.
6. Develop distribution strategy to reach target group.
7. Develop communication strategies and materials. Develop IEC materials
and approaches based on information and insights gained from focus groups
and individual interviews.
Training. Identify and train resource people who can support behaviour
change. Produce reference materials to reinforce the training of resource
people, including information about where they can go to ask for assistance.
8. Monitoring and evaluation. Ensure that a monitoring and evaluation plan is
in place.
These steps may be fine for introducing the FC. They however may not exactly
help us to integrate FC into existing programmes. With integration we need to
meet with those running different RH and HIV prevention programmes, agree
on entry points, adapt of materials, train service provider in other programme
areas, do joint monitoring of programmes etc
Barriers
There are many impediments to effective condom programming. To understand
how they work and how to overcome them, one must consider them in terms of
their personal, financial, political, national, global and health systems aspects. While
some of these impediments may be amenable to operational solutions such as
improved logistics and coordination, others are deeply rooted in society’s political,
social, cultural, legal and economic systems. Developing solutions to all of them
would be ideal. However, doing so remains difficult because the barriers are
formidable and, in many ways, interconnected. In this document, we will briefly
discuss personal barriers are they are most relevant for our work.
Personal barriers
Complaints about the physical qualities of male condoms are well known. One need
not have ever used condoms, or even seen one, to understand that they are
associated with an intimate and taboo-laden activity: sex. Many would-be users
8
Source: The Female Condom: A guide for planning and programming. (2000). WHO & UNAIDS.
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complain that they are “greasy,” unattractive, often have a rubbery smell and
interfere with the natural “spontaneity” of the sex act. They are the butt of jokes in
every language. They form a layer of insulation between the penis and the vagina
and, even after sensitive negotiations their use can still somehow imply a lack of
trust. To actually be used they have to be physically available at the moment of
intercourse (but often are not) and potential users must both be sufficiently
informed, sober and motivated.
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Chapter II: Male and Female Anatomy
Objectives
To provide information on the anatomy and physiology (functions) of the
male and female reproductive systems
Key Points
Male Sexual and Reproductive System9
The purpose of the organs of the male sexual and reproductive system is to
perform the following functions:
1. To produce, maintain and transport sperm (the male reproductive cells) and
protective fluid (semen)
2. To discharge sperm within the female reproductive tract during sex
3. To produce and secrete male sex hormones responsible for growth,
maturation and maintaining the male reproductive system and functions
4. To perform the procreation function
Unlike the female reproductive system, most of the male reproductive system is
located outside of the body. These external structures include the penis, scrotum,
and testicles and can produce pleasurable sensation when stimulated.
The Female Sexual and Reproductive System10
The female sexual and reproductive system is designed to carry out several
functions:
1. It produces the female egg cells necessary for reproduction, called the ova or
oocytes. The system is designed to transport the ova to the site of
fertilization.
2. Conception, the fertilization of an egg by a sperm, normally occurs in the
upper part of the fallopian tubes.
3. The next step for the fertilized egg is to implant into the walls of the uterus,
beginning the initial stages of pregnancy. If fertilization and/or implantation
Source: The Male Reproductive System. (2008). WebMD. Internet document, available on:
http://www.webmd.com/sex-relationships/guide/male-reproductive-system
10 Source: The Female Reproductive System. (2008). WebMD. Internet document, available on:
http://www.webmd.com/sex-relationships/guide/your-guide-female-reproductive-system
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does not take place, the system is designed to menstruate (the monthly
shedding of the uterine lining).
4. In addition, the female reproductive system produces female sex hormones
that maintain the reproductive cycle.
5. Pregnancy and breastfeeding functions.
Like male sexual and reproductive organs, the female organs can produce
pleasurable sensation when stimulated.
Overview
The following sections will present a detailed discussion of the male and female
organs relevant for sexual activity and condom use.
The Male Sexual and Reproductive System I don’t think we need to
repeat these points.
The purpose of the organs of the male reproductive system is to perform the
following functions:
1. To produce, maintain and transport sperm (the male reproductive cells) and
protective fluid (semen)
2. To discharge sperm within the female reproductive tract during sex
3. To produce and secrete male sex hormones responsible for maintaining the
male reproductive system
Unlike the female reproductive system, most of the male reproductive system is
located outside of the body. These external structures include the penis, scrotum,
and testicles.
Insert Diagrams
Penis: This is the male organ used in sexual intercourse.
It has 3 parts:
the root, which attaches to the wall of the abdomen;
the body, or shaft; and
the glans, which is the cone-shaped part at the end of the penis.
The glans, also called the head , is covered with a loose layer of skin called foreskin.
(This skin is sometimes removed in a procedure called circumcision.)
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The opening of the urethra, the tube that transports semen (also known as cum) and
urine, is at the tip of the penis. The penis also contains a number of sensitive nerve
endings. The body of the penis is cylindrical in shape and consists of 3 circular
shaped chambers. These chambers are made up of special, sponge-like tissue. This
tissue contains thousands of large spaces that fill with blood when the man is
sexually aroused. As the penis fills with blood, it becomes hard and erect, which
allows for penetration during sexual intercourse.
The skin of the penis is loose and elastic to accommodate changes in penis size
during an erection. Semen, which contains sperm (reproductive cells), is expelled
(ejaculated) through the end of the penis when the man reaches sexual climax
(orgasm). When the penis is erect, the flow of urine is blocked from the urethra,
allowing only semen to be ejaculated at orgasm.
Scrotum: This is the loose pouch-like sac of skin that hangs behind the penis. It
contains the testicles (also called testes), as well as many nerves and blood vessels.
The scrotum acts as a "climate control system" for the testes. For normal sperm
development, the testes must be at a temperature slightly cooler than body
temperature. Special muscles in the wall of the scrotum allow it to contract and
relax, moving the testicles closer to the body for warmth or farther away from the
body to cool the temperature.
Testicles (testes): These are two oval organs about the size of large olives that lie in
the scrotum, secured at either end by a structure called the spermatic cord. The
testes are responsible for making testosterone, the primary male sex hormone, and
for generating sperm. Within the testes are coiled masses of tubes called
seminiferous tubules. These tubes are responsible for producing sperm cells.
The internal organs of the male reproductive system, also called accessory organs,
include the following:
Epididymis: The epididymis is a long, coiled tube that rests on the backside of each
testicle. It transports and stores sperm cells that are produced in the testes. It also is
the job of the epididymis to bring the sperm to maturity, since the sperm that
emerge from the testes are immature and incapable of fertilization. During sexual
arousal, contractions force the sperm into the vas deferens.
Vas deferens: The vas deferens is a long, muscular tube that travels from the
epididymis into the pelvic cavity, to just behind the bladder. The vas deferens
transports mature sperm to the urethra, the tube that carries urine or sperm to
outside of the body, in preparation for ejaculation.
Ejaculatory ducts: These are formed by the fusion of the vas deferens and the
seminal vesicles (see below). The ejaculatory ducts empty into the urethra.
Urethra: The urethra is the tube that carries urine from the bladder to outside of
the body. In males, it has the additional function of ejaculating semen when the man
20
reaches orgasm. When the penis is erect during sex, the flow of urine is blocked
from the urethra, allowing only semen to be ejaculated at orgasm.
Seminal vesicles: The seminal vesicles are sac-like pouches that attach to the vas
deferens near the base of the bladder. The seminal vesicles produce a sugar-rich
fluid (fructose) that provides sperm with a source of energy to help them move. The
fluid of the seminal vesicles makes up most of the volume of a man's ejaculatory
fluid, or ejaculate.
Prostate gland: The prostate gland is a walnut-sized structure that is located below
the urinary bladder in front of the rectum. The prostate gland contributes additional
fluid to the ejaculate. Prostate fluids also help to nourish the sperm. The urethra,
which carries the ejaculate to be expelled during orgasm, runs through the centre of
the prostate gland.
Bulbourethral glands: Also called Cowper's glands, these are pea-sized structures
located on the sides of the urethra just below the prostate gland. These glands
produce a clear, slippery fluid that empties directly into the urethra. This fluid
serves to lubricate the urethra and to neutralize any acidity that may be present due
to residual drops of urine in the urethra.
How Does the Male Reproductive System Function?
The entire male reproductive system is dependent on hormones, which are
chemicals that regulate the activity of many different types of cells or organs. The
primary hormones involved in the male reproductive system are follicle-stimulating
hormone, luteinizing hormone, and testosterone.
Follicle-stimulating hormone is necessary for sperm production (spermatogenesis)
and luteinizing hormone stimulates the production of testosterone, which is also
needed to make sperm. Testosterone is responsible for the development of male
characteristics, including muscle mass and strength, fat distribution, bone mass,
facial hair growth, voice change and sex drive.
Human sexuality is how people experience and express themselves as sexual beings.[1]
The study of human sexuality encompasses an array of social activities and an
abundance of behaviors, actions, and societal topics. Biologically, sexuality can
encompass sexual intercourse and sexual contact in all its forms, as well as medical
concerns about the physiological or even psychological aspects of sexual behaviour.
Sociologically, it can cover the cultural, political, and legal aspects; and philosophically,
it can span the moral, ethical, theological, spiritual or religious aspects.
Human sexual behavior encompasses the search for a partner or partners, interactions
between individuals, physical, emotional intimacy, and sexual contact. Some cultures
21
discriminate against sexual contact outside of marriage. Eextramarital sexual activity is
perceived as pervasive. Unprotected sex may result in unwanted pregnancy or sexually
transmitted diseases. In some areas, sexual abuse of individuals is prohibited by law and
considered against the norms of society.
Heterosexuality involves individuals of opposite sexes. Different sexual practices are
limited by laws in many places. In some countries, mostly those where religion has a
strong influence on social policy, marriage laws serve the purpose of encouraging
people to only have sex within marriage. Sodomy laws were seen as discouraging
same-sex sexual practices, but may affect opposite-sex sexual practices. Laws also ban
adults from committing sexual abuse, committing sexual acts with anyone under an
age of consent, performing sexual activities in public, and engaging in sexual activities
for money (prostitution). Though these laws cover both same-sex and opposite-sex
sexual activities, they may differ with regards to punishment, and may be more
frequently (or exclusively) enforced on those who engage in same-sex sexual activities.
Homosexuality. Same-sex sexuality involves individuals of the same sex. It is possible
for a person whose sexual identity is mainly heterosexual to engage in sexual acts with
people of the same sex. For example, mutual masturbation in the context of what may
be considered normal heterosexual teen development. Gay, lesbian, and bisexual
people who pretend to be heterosexual are often referred to as being closeted, hiding
their sexuality in "the closet". "Closet case" is a derogatory term used to refer to people
who hide their sexuality. Making that orientation (semi-) public can be called "coming
out" in the case of voluntary disclosure or "outing" in the case of disclosure by others
against the subject's wishes. Among some communities (called "men on the DL" or
"down-low"), same-sex sexual behavior is sometimes viewed as solely for physical
pleasure. Men on the "down-low" may engage in sex acts with other men while
continuing sexual and romantic relationships with women.
Gender identity is a person's own sense of identification as male or female. The term is
intended to distinguish this psychological association, from physiological and
sociological aspects of gender. Gender identity is how one personally identifies
their/hir/her/his/yo's gender regardless of their sex characteristics. It does not have to
be either man or woman, but can be a combination of feminine, masculine and
androgynous feelings.
Sexual abuse. Sexual activity can also encompass sexual abuse - that is, coercive or
abusive use of sexuality. Examples include: rape, lust murder, child sexual abuse, and
zoosadism (animal abuse which may be sexual in nature), as well as (in many countries)
certain non-consensual paraphilias such as frotteurism, non-consensual exhibitionism
and voyeurism. Sexual abuse can occur amongst adults, children, adults and children
and amongst both (or all) sexes and genders.
22
The Female Reproductive System I think we could do without this
repetition. Alternatively, you may consider presenting the
information in text boxes if you feel the information requires
emphasis.
The female reproductive system is designed to carry out several functions. It
produces the female egg cells necessary for reproduction, called the ova or oocytes.
The system is designed to transport the ova to the site of fertilization. Conception,
the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The
next step for the fertilized egg is to implant into the walls of the uterus, beginning
the initial stages of pregnancy. If fertilization and/or implantation (pregnancy) does
not take place, the system is designed to menstruate (the monthly shedding of the
uterine lining). In addition, the female reproductive system produces female sex
hormones that maintain the reproductive cycle.
What Parts Make up the Female Anatomy?
The female reproductive system includes parts inside and outside the body.
Insert Diagrams
The function of the external female reproductive structures (the genitals) is twofold:
To enable sperm to enter the body and to protect the internal genital organs from
infectious organisms. The main external structures of the female reproductive
system include:
Labia majora: The labia majora enclose and protect the other external reproductive
organs. Literally translated as "large lips," the labia majora are relatively large and
fleshy. The labia majora contain sweat and oil-secreting glands. After puberty, the
labia majora are covered with hair.
Labia minora: Literally translated as "small lips," the labia minora can be very small
or up to 2 inches wide. They lie just inside the labia majora, and surround the
openings to the vagina (the canal that joins the lower part of the uterus to the
outside of the body) and urethra (the tube that carries urine from the bladder to the
outside of the body).
Bartholini's glands: These glands are located besides the vaginal opening and
produce a fluid (mucus) secretion that provides natural lubrication during sex,
provided the woman has been sexually aroused.
Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that
is comparable to the penis in males. The clitoris is covered by a fold of skin, called
the prepuce, which is similar to the foreskin at the end of the penis. Like the penis,
the clitoris is very sensitive to stimulation and can become erect.
23
The internal reproductive organs in the female include:
Vagina: The vagina is a canal that joins to the cervix (the lower part of uterus) to the
outside of the body. It also is known as the birth canal. This is the organ that
receives the penis during intercourse.
Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a
developing foetus. The uterus is divided into two parts: the cervix, which is the
lower part that opens into the vagina, and the main body of the uterus, called the
corpus. The corpus can easily expand to hold a developing baby. A channel through
the cervix allows sperm to enter and menstrual content to exit.
Ovaries: The ovaries are small, oval-shaped glands that are located on either side of
the uterus. The ovaries produce eggs and hormones after puberty until menopause.
Fallopian tubes (oviduct): These are narrow tubes that are attached to the upper
part of the uterus and serve as tunnels for the ova (egg cells) to travel from the
ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally
occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it
implants into the lining of the uterine wall.
Breasts: The mammary glands are in the breasts that produce and secrete milk
during the lactation process to feed the newborn. During pregnancy, high blood
estrogen and progesterone levels stimulate lactation. The corpus luteum produces
these hormones during early pregnancy; the placenta takes over later. The
hormones stimulate the ducts and glands in the breasts, enlarging the breasts.
What Happens During the Menstrual Cycle?
Females of reproductive age (from around 10 to 50 years) experience cycles of
hormonal activity that repeat at about one-month intervals. (Menstru means
"monthly"; hence the term menstrual cycle.) With every cycle, a woman's body
prepares for a potential pregnancy, whether or not that is the woman's intention.
The term menstruation refers to the periodic shedding of the uterine lining.
The average menstrual cycle takes about 28-32 days and occurs in phases: the
follicular phase, the ovulatory phase (ovulation), and the luteal phase.
There are four major hormones (chemicals that stimulate or regulate the activity of
cells or organs) involved in the menstrual cycle: follicle-stimulating hormone,
luteinizing hormone, estrogen, and progesterone.
Follicular Phase of the Menstrual Cycle
This phase starts on the first day of your period. During the follicular phase of the
menstrual cycle, the following events occur:
24
Two hormones are released from the brain and travel in the blood to the
ovaries.
The hormones stimulate the growth of about 15-20 eggs in the ovaries each
in its own "shell," called a follicle.
These hormones also trigger an increase in the production of the female
hormone estrogen.
As estrogen levels rise, like a switch, it turns off the production of folliclestimulating hormone.
As time passes, one follicle in one ovary becomes dominant and continues to
mature, while others stop growing and die.
Ovulatory Phase of the Menstrual Cycle
The ovulatory phase, or ovulation, starts about 14 days after the follicular phase
started. The ovulatory phase is the midpoint of the menstrual cycle, with the next
menstrual period starting about 2 weeks later. During this phase, the following
events occur:
The rise in estrogen from the dominant follicle triggers a surge in the amount
of hormones produced by the brain.
This causes the dominant follicle to release its egg from the ovary.
As the egg is released (a process called ovulation) it is captured by finger-like
projections on the end of the fallopian tubes (fimbriae).
Also during this phase, there is an increase in the amount and thickness of
mucous produced by the lower part of the uterus (cervix). I thought the
mucous decreases in thickness or becomes thinner to allow easier passage of
sperm. If a woman were to have intercourse during this time, the thick
mucus captures the man's sperm, nourishes it, and helps it to move towards
the egg for fertilization.
Luteal Phase of the Menstrual Cycle
The luteal phase of the menstrual cycle begins right after ovulation and involves the
following processes:
Once it releases its egg, the empty follicle develops into a new structure
called the corpus luteum.
This structure releases the hormone progesterone. Progesterone prepares
the uterus for a fertilized egg to implant.
If intercourse has taken place and a man’s sperm has fertilized the egg
(conception), the fertilized egg (embryo) will travel through the fallopian
tube to implant in the uterus. The woman is now considered pregnant.
If the egg is not fertilized, it passes through the uterus. Not needed to support
a pregnancy, the lining of the uterus breaks down and sheds, and the next
menstrual period begins.
25
How Many Eggs Does a Woman Have?
The vast majority of the eggs within the ovaries steadily die, until they are depleted
at menopause. At birth, there are approximately 1 million eggs; and by the time of
puberty, only about 300,000 remain. Of these, 300 to 400 will mature and be
ovulated during a woman's reproductive lifetime. The eggs continue to degenerate
during pregnancy, with the use of birth control pills, and in the presence or absence
of regular menstrual cycles.
26
Anal Sex11
As in the case with penis, vagina, testes, urethral etc, shall we also start with functions of
the anus and rectum like we did in previous passages. The anus is the opening to the
lower end of the digestive tract (in men and women) and is surrounded by two sets of
muscles called the anal sphincters. A person can learn to control the contractions of the
outer sphincter. The anal opening leards into the short anal canal and the larger
rectum. Perineal muscles support the area around the anus and are in close contact
with the bulb of the penis in the male and othe outer portion of the vagina in the feale.
All of these tissues are well supplied with blood vessels and nerves. This makes the
anal-penile intercourse pleasureable for some individuals, but also makes the anal
cavity highly susceptible to HIV.
The inner third of the anal canal is less ensitive to touch than the outer two-thirds, but is
more sensitive to preassure. The rectum is a curved tube about eight or nine inches
long and has the capacity, like the anus, to expand.
One form of anal intercourse involves the insertion of an object into the anus. The
object may be a finder, penis, dildo, or other objects. Some people engage is “fisting”
which is the insertion of the hand and sometimes part of the forearm into the anus and
rectum.
For some, the pleasure derived from penetration of the anus is both physical and
psychological. Psychological satisfaction may be derived by the feelings of dominance
and submission produced in the particpants. Fantasy is often an important factor in
achieving satisfaction. The stimulation of the nerve endings in the tissues and muscles,
the bulb of the penis, and connections to the vagina; the feeling of fullness in the
rectum; and the rubbing against the prostate gland in the male, create physical
pleasure in many. Various objects may be used to stimulate the anus.
The anus is also used sexually (in males and females) in ways that do not involve
penetration. The rubbing of the external sphincter and the flexing of the muscle are
common. Anilingus (rimming) – or the kissing, licking, sucking and insertion of the
tongue into the anus is common.
Contrary to the popular belief, anal sex is not an activity exclusive to the male
homosexual. In some societies, heterosexual couples engage in anal sex in order to
protect the “vaginal virginity” of the female partner, which may be socio-culturally
appropriate. Anal sex is at times practiced as means of contraception. Some studies
report that 47% of predominantly heterosexual men and 61% of the women have tried
anal intercourse. Thirteen percent of married couples reported having anal intercourse
at least once a month. Approximately 37% of both men and women have practice oral11
Bullough VL & Bullough B. (1994). Human Sexuality: An Encyclopedia. Taylor & Francis.
27
anal contact.
Certain precautions must be followed if practicing anal sex. Penetration should be done
slowly and carefully by a penis or a soft rubber object that has no sharp edges or points.
Anything inserted into the anus should be well covered by a water-based lubricant and
a condom. The pain of insertion can be overcome by the inserted by practicing
relaxation techniques and, if done properly, there should be no tearing of the soft anal
tissues. Positioning of the inserted object is important because of the curve of the
rectum. Fisting is an activity that should be practiced with great care (if at all). Few
people are capable of relaxing enough to accommodate something as big as an arm in
their anus and there is real dnages of damage to the delicate rectal tissues.
Disease-causing orgasms can be transmitted during anal sex. These include HIV,
syphyilis, gonnorhea, nongonococcal urethritis, herpes, anal warts, hepatitis, and
various organisms that cause intestinal infections. They can also be transmitted from
anus to mouth or to vagina if a penis or dildo is not thoroughly cleaned.
Anilingus (rimming) is another activity that presents an avenue for both pleasure but
also disease transmission.
28
Chapter III: Reproductive Health
Objectives
To introduce basic issues related to reproductive health, sexual health and
reproductive rights.
To clarify concepts such as:
o Family planning,
o Maternal health including antenatal care, child birth and postnatal
care
o Gender-based violence
o Prevention of mother-to-child transmission of HIV, and
o Voluntary counselling and testing.
Key Points
Reproductive Health
Reproductive health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity, in all matters relating to the
reproductive system and to its functions and processes for all people.12
Reproductive health therefore implies that people are able to have a satisfying and
safe sex life and that they have the capability to reproduce and the freedom to decide
if, when and how often to do so. Implicit in this last condition is the right of men and
women to be informed and to have access to safe, effective, affordable and acceptable
methods of family planning of their choice, as well as other methods of their choice for
regulation of fertility which are not against the law, and the right of access to
appropriate health-care services that will enable women to go safely through
pregnancy and childbirth and provide couples with the best chance of having a healthy
infant…13
Sexual Health
Sexual health has always been closely linked with reproductive health, particularly
since the International Conference on Population and Development (ICPD) in 1994,
which defined RH as incorporating sexual health. However, recently this
12
13
UN International Conference on Population and Development (1994). UN. Cairo, Egypt.
Ibid.
29
conceptualization has been advanced, with the recognition that sexual health is
broader and more encompassing than reproductive health.14
Rather than being a component, sexual health should be seen as a necessary
underlying condition for reproductive health, while at the same time being relevant
throughout the life span and not only during the reproductive years.15
Sexual and reproductive rights are complicated for people living with HIV who
know their status as they have the additional stress of disclosing their HIV status in
new relationships, which can lead to stigma and discrimination. Once people are
found to be HIV-positive, it is often assumed both by them and by the world at large
that their sex lives should cease. Yet there is no scientific reason why this should be
the case. Many HIV-positive women in discordant relationships have continued to
have sex with their partners for many years, whilst ensuring that their partners
remain HIV-negative through using condoms. The world is also encouraged by the
new research showing antiretroviral treatment may be used effectively for
prevention. Indeed, sexual pleasure is a fundamental part of all our lives and sexual
intimacy is known to play a valuable part in maintaining psychological wellbeing.
We are all sexual beings whether or not we choose to engage in sex. To pretend
otherwise is to deny a fundamental part of our existence as human beings.16
The field of sexual health encompasses a range of issues, including:
STIs, including HIV, and reproductive tract infections (RTIs);
Unintended pregnancy and unsafe abortion;
Infertility;
Sexual well-being of both HIV affected and infected communities (including
sexual satisfaction, pleasure and dysfunction);
Violence related to gender and sexuality;
Certain aspects of mental health;
Impact of physical disabilities and chronic illnesses on sexual health;
Reproductive Rights
Around the world, every minute 380 women get pregnant, 190 women face an
unintended pregnancy, 110 women face a pregnancy-related problem, 40 women
undergo an unsafe abortion, 30 are injured or disabled, and 1 woman dies17.
Butler, P.A. (2004). Sexual Health – A New Focus for WHO. Progress in Reproductive Health. WHO.
No. 67. (p. 2).
15 Butler, P.A. (2004). Sexual Health – A New Focus for WHO. Progress in Reproductive Health. WHO.
No. 67. (p. 2).
16 Sophie Dilmitis, World YWCA.
17 CHEDRES. (2009). Safe Motherhood. Internet document, available at:
http://www.chedres.org/safemotherhood/
14
30
Reproductive rights rest on the recognition of the basic right of all couples and
individuals to decide freely and responsibly the number, spacing and timing of their
children and to have the information and means to do so, and the right to attain the
highest standard of sexual and reproductive health. They also include the right of all
to make decisions concerning reproduction free of discrimination, coercion and
violence.
PLHIV should have the same rights as people who are not infected with HIV. In an
effort to control the epidemic, many governments have passed laws that criminalise
the transmission of HIV. Criminalisation of transmission can happen by creating
laws specifically aimed at HIV transmission. For example, a person could be charged
with the act of transmitting HIV to another person. Or second, prosecutors can use
existing laws to prosecute the transmission of HIV. For example, a person could be
charged with ‘reckless endangerment’ for having sex with their partner even if there
is no law that specifically makes it a criminal act to transmit HIV18.
According to Planned Parenthood, 58 countries worldwide have laws that
criminalise HIV or use existing laws to prosecute people for transmitting the virus.
Another 33 countries are considering similar legislation.
Criminalising HIV has further repercussions for women, especially pregnant women
who in many countries are now being prosecuted for endangering the foetus. As
such, women whose babies are born HIV-positive could be prosecuted for
transmitting HIV to their newborn. And this despite the fact that even when
antiretroviral treatment is used during the perinatal period, there is stills a 1-2%
chance of transmission! As we can see, women are prime targets for this as pregnant
women are often the first to be tested when they access reproductive health
services. All of this is happening in a time where only a quarter of HIV-positive
pregnant women in poorer countries receive antiretroviral therapy to prevent
perinatal transmission. Women are increasingly vulnerable to unfair prosecution in
the environment of routine opt-out testing. Opt-out testing is defined as performing
HIV screening after notifying the patient that 1) the test will be performed and 2)
the patient may elect to decline or defer testing. Assent is inferred unless the
patient declines testing.
Most people spread HIV when they do not know their status. Furthermore these
laws drive people underground and further away from voluntary counseling and
testing as these laws place all the onus of responsibility on the HIV positive person.
Criminalisation further discourages open dialogue around HIV and AIDS.
The Universal Declaration of Human Rights states that “All human beings are born
free and equal in dignity and rights.” This idea provides a foundational principle for
all advocacy efforts against the criminalisation of HIV. Christian organisations
18
Aziza Ahmed and featured in ICW News Issue 40 April/May 2008
31
should insist that HIV-positive people not be subjected to criminalisation or other
coercive measures solely on the basis of their HIV status19. Advocates must demand
that human rights principles of non-discrimination, equality, and due process must
be respected in all lawmaking specific to HIV and AIDS20.
Family planning
Family planning allows individuals and couples to anticipate and attain their desired
number of children and the spacing and timing of their births. It is achieved through
use of contraceptive methods and the treatment of involuntary infertility. A
woman’s ability to space and limit her pregnancies has a direct impact on her health
and well-being as well as on the outcome of each pregnancy.21 All people, including
men and women affected or infected by HIV should have the right to family planning
services.
Overview
Reproductive health services and HIV22
RH services provide an entry point for young sexually active men and women
into the healthcare system. These services provide opportunities for the
provision of a range of HIV prevention, care, and treatment, including
voluntary counseling and testing, condom promotion, management of
sexually transmitted infections, access to male circumcision, and prevention
of mother to child transmission (PMTCT)of HIV.
Condom distribution for HIV prevention can piggyback onto current public
sector condom distribution efforts that primarily target family planning
users.
Family planning is an important and relatively unrecognized tool for
preventing HIV transmission.
In addition, clients receiving HIV services need access to comprehensive and quality
reproductive health services, including family planning.
In many countries RH services are under-funded and inadequate, which undermines
both HIV and RH goals. The role of family planning in HIV prevention needs to be
highlighted. Helping HIV positive women avoid an unwanted pregnancy is one of the
most cost-effective HIV interventions available but it is important that positive
women who would like to have children are supported and followed up with the
19
UNAIDS
International Community of Women Living with HIV and AIDS – why we oppose criminalisation
WHO. (2009). Family Planning. Internet document, available at:
http://www.who.int/topics/family_planning/en/
22 Source: Issues Brief: Global Fund Supports Reproductive Health Commodity Security. (2008). USAID:
Washington. Online document, available at:
http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/GlobFundSuppRHCS.pdf
20
21
32
appropriated services and support that they need in order to ensure the safety of
both the mother and child. Estimates suggest that adding FP services to PMTCT
programs can prevent two times the number of HIV infections and four times the
number of child deaths as Nevirapine treatment. Experts at the World Health
Organization and Johns Hopkins University also advocate that decreasing HIV
transmissions to infants requires not only continued efforts in reducing HIV
infections in women and increasing the reach of PMTCT, but also reducing
unintended pregnancy. Unmet need for contraception is high in Sub-Saharan Africa,
which is the region where HIV infection rates are the highest and where challenges
in implementing comprehensive PMTCT programs are the most significant. Some
experts argue that given the high levels of unmet need for FP and HIV prevalence, as
well as the low levels of knowledge of HIV status by those infected, simply reducing
unmet need for all women would go a long way in reducing HIV transmission.
Improving Reproductive Health
Everyone has the right to enjoy reproductive health, which is a basis for having
healthy children, intimate relationships and happy families. Reproductive health
encompasses the following principles: that every child is wanted, every birth is safe,
every young person is free of HIV, men and boys have RH needs that should be
addressed and every girl and woman is treated with dignity and respect. For women
and girls already living with HIV they also have the right to comprehensive
reproductive health services.
But reproductive health problems remain the leading cause of ill health and death
for women of childbearing age worldwide. Impoverished women, especially those
living in developing countries, suffer disproportionately from unintended
pregnancies, maternal death and disability, sexually transmitted infections including
HIV, gender-based violence and other problems related to their reproductive system
and sexual behaviour. Because young people often face barriers in trying to get the
information or care they need, adolescent reproductive health is another important
focus of reproductive health programming.
Supporting the Constellation of Reproductive Rights
During the 1990s, a series of important United Nations conferences emphasized that
the well-being of individuals, and respect for their human rights, should be central
to all development strategies. Particular emphasis was given to reproductive rights
as a cornerstone of development.
Reproductive rights were clarified and endorsed internationally in the Cairo
Consensus that emerged from the 1994 ICPD. This constellation of rights, embracing
fundamental human rights established by earlier treaties, was reaffirmed at the
Beijing Conference and various international and regional agreements since, as well
as in many national laws. They include the right to decide the number, timing and
33
spacing of children, the right to voluntarily marry and establish a family, and the
right to the highest attainable standard of living, among others.
What Are Reproductive Rights?
Attaining the goals of sustainable, equitable development requires that individuals
are able to exercise control over their sexual and reproductive lives. This includes
the rights to:
Reproductive health as a component of overall health, throughout the life
cycle, for both men and women, both infected and affected by HIV and other
STIs
Reproductive decision-making, including voluntary choice in marriage,
family formation and determination of the number, timing and spacing of
one's children and the right to have access to the information and means
needed to exercise voluntary choice
Equality and equity for men and women, to enable individuals to make free
and informed choices in all spheres of life, free from discrimination based on
gender and or sexuality
Sexual and reproductive security, including freedom from sexual violence
and coercion, and the right to privacy.
Reproductive Rights and International Development Goals
The importance of reproductive rights in terms of meeting international
development goals has increasingly been recognized by the international
community. In the September 2005 World Summit, the goal of universal access to
reproductive health was endorsed at the highest level. Reproductive rights are
recognized as valuable ends in themselves, and essential to the enjoyment of other
fundamental rights. Special emphasis has been given to the reproductive rights of
women and adolescent girls, and to the importance of sex education and
reproductive health programmes.
Reproductive Rights for Women Living with HIV
Many times positive women who go to antenatal clinics face extreme discrimination.
The International Community of Women Living with HIV and AIDS reports that HIV
positive women are often made to stand in separate lines when waiting to see a
health-care provider, are told that they should not be pregnant, are not offered any
confidentiality and in their health folders are branded as HIV-positive for the world
to see.
Women Living with HIV should be able to:
Plan a pregnancy – implicit in this if a woman is not living with HIV she
should have the right to protection at conception.
Talk through with a health-care provider what the best treatment is – this
must be done in a friendly environment
34
Think about how the birth will take place and have options to caesarean
section or natural birth if she so wishes. And following the birth
Discuss the pros and cons of breastfeeding especially with no access to clean
water and given that in many parts of Africa, the entire family looks after the
child and not just the mother.
Life Cycle Approach
Reproductive health is a lifetime concern for both women and men, from infancy to
old age. UNFPA supports programming tailored to the different challenges they face
at different times in life.
In many cultures, the discrimination against girls and women that begins in infancy
can determine the trajectory of their lives. The important issues of education and
appropriate health care arise in childhood and adolescence. These continue to be
issues in the reproductive years, along with family planning, sexually transmitted
infections and reproductive tract infections, adequate nutrition and care in
pregnancy, and the social status of women and concerns about cervical and breast
cancer.
Male attitudes towards gender and sexual relations arise in boyhood, when they are
often set for life. Men need early socialization in concepts of sexual responsibility
and ongoing education and support in order to experience full partnership in
satisfying sexual relationships and family life.
Critical Messages for Different Life Stages
In its advocacy and programming, UNFPA focuses on key messages that can
empower both women and men at different stages of their lives.
Girls and Boys
Inform and empower girls to delay pregnancy until they are physically and
emotionally mature.
Inspire and motivate boys and men to be sexually responsible partners and
value daughters equally as sons.
Encourage governments to take responsibility for the human catastrophe of
orphans and other children who live in the streets.
Adolescents
Reorient health education and services to meet the diverse needs of
adolescents. Integrated reproductive health education and services for young
people should include family planning information, and counselling on
gender relations, STIs and HIV/AIDS, sexual abuse and reproductive health.
Ensure that health care programmes and providers' attitudes allow for
adolescents' access to the services and information they need.
35
Support efforts to eradicate female genital cutting and other harmful
practices, including early or forced marriage, sexual abuse, and trafficking of
adolescents for forced labour, marriage or forced prostitution.
Socialize and motivate boys and young men to show respect and
responsibility in sexual relations.
Ensure that young women living with HIV are not coerced into sterilisation
because of their status.
Adulthood
Improve communication between men and women on issues of sexuality and
reproductive health, and the understanding of their joint responsibilities, so
that they are equal partners in public and private life.
Enable women, especially women living with HIV to exercise their right to
control their own fertility and their right to make decisions concerning
reproduction, free of coercion, discrimination and violence.
Improve the quality and availability of reproductive health services and
barriers to access.
Reorient and strengthen health care services to better meet the needs of men
Skilled attendance at birth.
Make emergency obstetric care available to all women who experience
complications in their pregnancies.
Encourage men's responsibility for sexual and reproductive behaviour and
increase male participation in family planning.
The Older Years
Reorient and strengthen health care services to better meet the needs of
older women.
Support outreach by women's NGOs to help older women in the community
to better understand the importance of girls' education, reproductive rights
and sexual health so that they may become effective transmitters of this
knowledge.
Develop strategies to better meet needs of the elderly for food, water, shelter,
social and legal services and health care.
Information and services on menopause
Family planning23
Family planning allows individuals and couples to anticipate and attain their desired
number of children and the spacing and timing of their births. It is achieved through
use of contraceptive methods and the treatment of involuntary infertility. A
woman’s ability to space and limit her pregnancies has a direct impact on her health
and well-being as well as on the outcome of each pregnancy. This is also true for
women living with HIV.
Source: Family Planning. (2008). WHO: Geneva. Online document, available at:
http://www.who.int/topics/family_planning/en/
23
36
Antenatal care24
Antenatal Care (ANC) means "care before birth", and includes education,
counselling, screening and treatment to monitor and to promote the well-being of
the mother and foetus. The current challenge is to find out which type of care and in
what quantity is considered sufficient to ensure good quality of care for low-risk
pregnant women. Only interventions of proven effectiveness, for which benefits
largely overcome possible harms, and those acceptable to pregnant women and
their families, should be offered.
Evidence-based effective interventions for ANC include:
antenatal education for breast feeding;
Counselling on post-partum family planning options
energy/protein supplementation in women at risk for low birth weight;
folic acid supplementation to all women before conception and up to 12
weeks of gestation to avoid neural tube defects in the foetus;
iodine supplementation in populations with high levels of cretinism;
calcium supplementation in women at high risk of gestational hypertension
and in communities with low dietary calcium intake;
smoking and alcohol consumption cessation for reducing low birth weight
and preterm delivery;
acupressure (sea bands) and ginger for nausea control;
bran or wheat fibre supplementation for constipation;
exercise in water, massages and back care classes for backache;
screening for pre-eclampsia with a comprehensive strategy including an
individual risk assessment at first visit, accurate blood pressure
measurement, urine test for proteinuria and education on recognition of
advanced pre-eclampsia symptoms;
anti-D given during 72 hours postpartum to Rh-negative women who have
had a Rh-positive baby;
Down's syndrome screening;
screening and treatment of asymptomatic bacteriuria during pregnancy;
screening of hepatitis B infection for all pregnant women and delivery of
hepatitis B vaccine and immunoglobulin to babies of infected mothers;
screening for HIV in early pregnancy, a short course of antiretroviral drugs,
and caesarean section for infected mothers at 38 weeks, to reduce vertical
transmission;
For women who are already living with HIV – ensure that they are on the
right types of antiretrovirals that will not interfere with the development of
the foetus.
screening for rubella antibody in pregnant women and postpartum
vaccination for those with negative antigen;
Source: What is the effectiveness of antenatal care? (2006). Health Evidence Network. WHO:
Geneva. Online document, available at:
http://www.euro.who.int/HEN/Syntheses/antenatalsupp/20051219_11
24
37
screening and treatment of syphilis;
routine ultrasound early in pregnancy (before 24 weeks);
external cephalic version at term (36 weeks) by skilled professionals, for
women who have an uncomplicated singleton breech pregnancy; and
a course of corticosteroids given to women at risk of preterm delivery to
reduce respiratory distress syndrome in the baby and neonatal mortality.
Sexual intercourse and moderate aerobic exercise have been found safe during
pregnancy.
Antenatal care from midwives or general practitioners in low-risk pregnancies is
cost-effective. A model of ANC with a restricted number of visits for low-risk women
has been shown to be safe, more sustainable, and possibly as effective as models
with higher number of visits.
While for some interventions there is clear evidence of effectiveness or
ineffectiveness, for many there is still uncertainty due to a lack of well-conducted
randomized trials.
Prevention of Mother-to-Child Transmission or Vertical
Transmission of HIV25
Passing on of HIV from a HIV-positive mother to her child during pregnancy, labour,
delivery of breastfeeding is called vertical transmission or mother-to-child
transmission (MTCT). An estimated 420 000 children were newly infected with HIV
in 2007. Vertical transmission is almost entirely preventable, where services are
available, however the coverage levels are remarkably low in most resource-limited
countries. Global access to interventions to prevent HIV infections in infants was a
key concern at the UN General Assembly Special Session (UNGASS) on HIV/AIDS in
2001, where the Member States committed themselves to the goal of reducing the
proportion of infants infected with HIV by 20% by the year 2005 and by 50% by the
year 2010.
PMTCT is successful through use of family planning, including correct and
consistant use of male and female condoms, but also though correct drug regiments
for both the mother and the baby and correct breast or formula feeding techniques.
HIV Testing and Counselling26
HIV testing and counseling are critical entry points to life-sustaining healthcare
services for people living with HIV and AIDS, and effective means of reducing harm
Source: Mother-to-Child Transmission of HIV. (2008). WHO: Geneva. Online document, available at:
http://www.who.int/hiv/topics/mtct/en/index.html
26 Source: HIV Testing and Counselling. (2008). WHO: Geneva. Online document, available at:
http://www.who.int/hiv/topics/vct/en/index.html
25
38
in non-infected individuals and service delivery models need to be expanded to
testing in family planning, maternal and child health services, sexually transmitted
infection clinics, in-patient wards as well as free-standing client-initiated testing
centres.
Over the past 20 years, voluntary counselling and testing programs (VCT) have
supported millions of people learn their HIV status, yet more than 80% of people
living with HIV in low and middle-income countries do not know that they are
infected. Efforts are urgently needed to increase the provision of HIV testing
through a wider range of effective and safe options.
The WHO/UNAIDS guidance advises that health care providers globally should
recommend HIV testing and counselling to all patients who present with conditions
that might suggest underlying HIV disease.27
In generalized HIV epidemics, HIV testing and counselling should be recommended
to all patients attending all health facilities, whether or not the patient has
symptoms of HIV disease and regardless of the patient's reason for attending the
health facility. In concentrated and low-level HIV epidemics, depending on the
epidemiological and social context, countries should consider recommending HIV
testing and counselling to all patients in selected health facilities (e.g. antenatal,
tuberculosis, family planning, sexual health, and health services for most-at-risk
populations) as well as adolescents and children.
Other key recommendations In addition to key WHO/UNAIDS recommendations for provider-initiated HIV
testing and counselling in health facilities, otherwise known as Opt- out testing,
include:
All HIV testing must be voluntary, confidential, and undertaken with the
patient's consent.
Patients have the right to decline the test. They should not be tested for HIV
against their will, without their knowledge, without adequate information or
without receiving their test results.
Pre-test information and post-test counselling remain integral components
of the HIV testing process.
Patients should receive support to avoid potential negative consequences of
knowing and disclosing their HIV status, such as discrimination or violence.
Testing must be linked to appropriate HIV prevention, treatment, care and
support services.
Decisions about HIV testing in health facilities should always be guided by
what is in the best interests of the individual patient.
Provider-initiated HIV testing and counselling is not, and should not be
construed as, an endorsement of coercive or mandatory HIV testing.
Source: Provider initiated HIV testing and counseling in health facilities. (2007). WHO & UNAIDS:
Geneva. Online document, available at: http://www.who.int/hiv/topics/vct/PITC/en/index.html
27
39
Implementation of provider-initiated HIV testing and counselling should be
undertaken in consultation with key stakeholders, including civil society
groups, acknowledging that what works and is ethical will inevitably differ
across countries.
When implementing provider-initiated HIIV testing and counselling, equal
efforts must be made to ensure that a supportive social, policy and legal
framework is in place to maximize positive outcomes and minimize potential
harms to patients.
A system that monitors and evaluates the implementation and scale-up of
provider-initiated testing and counselling should be developed and
implemented concurrently.
As countries work towards Universal Access to HIV prevention, treatment, care and
support, the new guidance on provider-initiated HIV testing and counselling offers
an important opportunity to introduce new approaches and improve the standards
of HIV testing and counselling in both public and private health facilities. Together
with their partners, WHO and UNAIDS will continue to help countries expand access
to the full range of HIV testing and counselling services, as well as to other needed
health sector interventions against HIV/AIDS.
40
Chapter IV: Basics about Sexually Transmitted
Infections and HIV
Objectives
To explain what sexually transmitted infections are and what their impact on
wellbeing of individuals and communities can be
To outline strategies for preventing and treating sexually transmitted
infections
Key Points
Sexually Transmitted Infections28
Common Sexually Transmitted Infections (STIs) are infections that are spread
primarily through person-to-person sexual contact. There are more than 30
different sexually transmissible bacteria, viruses and parasites.29
In many cases, some STIs have no symptoms (such as burning during urination, puss
from the penis or vagina, etc.). Additionally, some STIs are ulcerative and other are
not. In other words, some STIs may cause open sores on the penis, vagina, anus or
the mouth and others do not. Existance of sores increases the risk of passing on and
and acquiring HIV and other STIs.
The most common STIs are Gonorrhoea, chlamydia infection, Syphilis,
Trichomoniasis, Chancroid, Genital Herpes, Genital Warts, Human
Immunodeficiency Virus (HIV) infection and Hepatitis B infection.
Several, in particular HIV and syphilis, can also be transmitted from mother to child
during pregnancy and childbirth, and through blood products and tissue transfer.
STIs can have severe consequences for individuals and communities. Apart from
being serious diseases on their own, the presence of untreated Sexually Transmitted
and other Reproductive Tract Infections (STI/RTI) can increase the risk of HIV
infection and transmission by a factor of two to nine.30
Source: Sexually Transmitted Infections. (2008). WHO: Geneva. Online document, available at:
http://www.who.int/topics/sexually_transmitted_infections/en/
29 Source: Sexually Transmitted Infections. (2008). WHO: Geneva. Online document, available at:
http://www.who.int/topics/sexually_transmitted_infections/en/
30 Source: Breaking the Cycle of Sexually Transmitted Infections. (2008). UNFPA: New York. Online
document, available at: http://www.unfpa.org/rh/stis.htm
28
41
Globally, some 340 million new cases of curable STIs occur every year.31 The figure
does not include HIV or other viral STIs — including hepatitis B, genital herpes and
genital warts, which are not curable.
Sexually transmitted infections continue to take an enormous toll on health,
particularly on women’s reproductive health. In fact, next to complications of
pregnancy and childbirth, they are the leading cause of health problems for women
of reproductive age. They can cause pregnancy-related complications, including
spontaneous abortions, premature birth, stillbirth and congenital infections. They
can also lead to pelvic inflammatory disease and cervical cancer.32
Overview
Sexually transmitted infections
Some of the commonest sexually transmitted pathogens can be divided into those
caused by bacteria, viruses and parasites.
Common bacteria and related infections
Neisseria gonorrhoeae (causes Gonorrhoea or gonococcal infection)
Chlamydia trachomatis (causes chlamydia infections)
Treponema pallidum (causes Syphilis)
Haemophilus ducreyi (causes Chancroid)
Klebsiella granulomatis (previously known as Calymmatobacterium
granulomatis causes Granuloma Inguinale or Donovanosis).
Common virus and related infections
Human immunodeficiency virus (causes AIDS)
Herpes simplex virus type 2 (causes genital herpes)
Human papillomavirus (causes genital warts and certain subtypes lead to
cervical cancer in women)
Hepatitis B virus (causes hepatitis and chronic cases may lead to cancer of
the liver)
Cytomegalovirus (causes inflammation in a number of organs including the
brain, the eye, and the bowel).
Common parasites and related infections
Trichomonas Vaginalis (causes vaginal trichomoniasis)
Candida Albicans (causes vulvovaginitis in women; inflammation of the glans
penis and foreskin [balano-posthitis] in men).
Source: Breaking the Cycle of Sexually Transmitted Infections. (2008). UNFPA: New York. Online
document, available at: http://www.unfpa.org/rh/stis.htm.
32 Source: Breaking the Cycle of Sexually Transmitted Infections. (2008). UNFPA: New York. Online
document, available at: http://www.unfpa.org/rh/stis.htm.
31
42
STI syndromes and the syndromic approach to patient management33
Although many different pathogens cause STIs, some of them give rise to similar or
overlapping clinical appearances, known as signs (what the individual or the healthcare provider sees on examination) and symptoms (what the patient feels, such as
pain or irritation). Some of these signs and symptoms are easily recognizable and
consistent, giving what is known as a syndrome that signals the presence of one or a
number of pathogens. For example, a discharge from the urethra in men can be
caused by Gonorrhoea alone, chlamydia alone or both together.
The main syndromes of common STIs
Urethral discharge
Genital ulcers
Inguinal swellings (bubo, which is a swelling in the groin)
Scrotal swelling
Vaginal discharge
Lower abdominal pain
Neonatal eye infections (conjunctivitis of the newborn)
The traditional method of diagnosing STIs is by laboratory tests. However, these are
often unavailable or too expensive. Since 1990 WHO has recommended a syndromic
approach to diagnosis and management of STIs in patients presenting with
consistently recognized signs and symptoms of particular STIs.
Sexually transmitted infections as a public health issue
In developing countries, STIs and their complications rank in the top five disease
categories for which adults seek health care. Infection with STIs can lead to acute
symptoms, chronic infection and serious delayed consequences such as infertility,
ectopic pregnancy, cervical cancer and the untimely death of infants and adults.
Prevention of STIs
The most effective means to avoid becoming infected with or transmitting a sexually
transmitted infection is to abstain from sexual intercourse (i.e., oral, vaginal, or anal
sex) or to have sexual intercourse only within a long-term, mutually monogamous
relationship with an uninfected partner. Male and female condoms, when used
consistently and correctly, are highly effective in reducing the transmission of HIV
and other sexually transmitted infections, including gonorrhoea, chlamydial
infection and trichomoniasis.
STIs and prevention of serious complications in women
STIs have serious health consequences on both women and men. They are the main
preventable cause of infertility, particularly in women. Between 10% and 40% of
women with untreated chlamydial infection develop symptomatic pelvic
inflammatory disease. Post-infection tubal damage is responsible for 30% to 40% of
WHO. (2007). Sexually Transmitted Infections Factsheet. Internet document, available at:
http://www.who.int/mediacentre/factsheets/fs110/en/
33
43
cases of female infertility. Furthermore, women who have had pelvic inflammatory
disease are 6 to 10 times more likely to develop an ectopic (tubal) pregnancy than
those who have not, and 40% to 50% of ectopic pregnancies can be attributed to
previous pelvic inflammatory disease. Infection with certain types of the human
papillomavirus can lead to the development of genital cancers, particularly cervical
cancer in women.
STIs and adverse outcomes of pregnancy
Untreated sexually transmitted infections are associated with congenital and
perinatal infections in neonates, particularly in the areas where rates of infection
remain high. In pregnant women with untreated early syphilis, 25% of pregnancies
result in stillbirth and 14% in neonatal death – an overall perinatal mortality of
about 40%.
STIs and HIV
The presence of an untreated ulcerative or non-ulcerative (those STIs which cause
ulcers or those which do not) infection increases the risk of both acquisition and
transmission of HIV by a factor of up to 10. Thus, prompt treatment for STIs is
important to reduce the risk of HIV infection. Controlling STIs is important for
preventing HIV in people at high risk, as well as in the general population.
Global strategy for the prevention and control of STIs
The control of STIs remains a priority for WHO which urges all countries to control
the transmission of STIs by implementing a number of interventions, including the
following:
Prevention by promoting safer sexual behaviours;
General access to quality condoms at affordable prices;
Promotion of early recourse to health services by people suffering from STIs
and by their partners;
Inclusion of STI treatment in basic health services;
Specific services for populations with frequent or unplanned high-risk sexual
behaviours - such as sex workers, adolescents, long-distance truck-drivers,
military personnel, substance users and prisoners;
Proper treatment of STIs, i.e. use of correct and effective medicines,
treatment of sexual partners, education and advice;
Screening of clinically asymptomatic patients, where feasible; (e.g. syphilis,
chlamydia);
Provision for counselling and voluntary testing for HIV infection;
Prevention and care of congenital syphilis and neonatal conjunctivitis; and
Involvement of all relevant stakeholders, including the private sector and the
community, in prevention and care of STIs.
44
STI management
Presently, the healthcare community has achieved standardization for STI
management. Details follow below.
Rationale for standardized treatment recommendations
Effective management of STIs is one of the cornerstones of STI control, as it
prevents the development of complications and sequelae, decreases the spread of
those infections in the community and offers a unique opportunity for targeted
education about HIV prevention.
Appropriate treatment of STIs at the first contact between patients and health care
providers is, therefore, an important public health measure. It is strongly
recommended that countries establish and use national standardized treatment
protocols for STIs. These can help quality of care and quality of pre- and in-service
training for healthcare professionals.
Case management
STI case management is the care of a person with an STI-related syndrome or with a
positive test for one or more STIs, including HIV. The components of case
management include:
history taking,
clinical examination,
correct diagnosis, pre- and post-test counselling ,
early and effective treatment,
risk assessment
advice on sexual behaviour and counselling ,
promotion and/or provision of condoms,
partner notification and treatment,
case reporting and
clinical follow-up as appropriate.
Thus, effective case management consists not only of antimicrobial therapy to
obtain cure and reduce infectivity, but also comprehensive consideration and care of
the patient’s sexual and reproductive health.
Syndromic management
Etiological diagnosis of STIs is problematic for health care providers in many
settings. It places constraints on their time and resources, increases costs and
reduces access to treatment. In addition, the sensitivity and specificity of
commercially available tests can vary significantly, affecting negatively the
reliability of laboratory testing for STI diagnosis.
To overcome this problem, a syndrome-based approach to the management of STI
patients has been developed and promoted in a large number of countries in the
developing world. The syndromic management approach is based on the
45
identification of consistent groups of symptoms and easily recognized signs
(syndromes), and the provision of treatment that will deal with the majority of, or
the most serious, organisms responsible for producing a syndrome.
Description of some STIs
Bacterial Vaginosis34
What is bacterial vaginosis?
Bacterial Vaginosis (BV) is the name of a condition in women where the normal
balance of bacteria in the vagina is disrupted and replaced by an overgrowth of
certain bacteria. It is sometimes accompanied by discharge, odour, pain, itching, or
burning.
What are the signs and symptoms of bacterial vaginosis?
Women with BV may have an abnormal vaginal discharge with an unpleasant odor.
Some women report a strong fish-like odor, especially after intercourse. Discharge,
if present, is usually white or gray; it can be thin. Women with BV may also have
burning during urination or itching around the outside of the vagina, or both.
However, most women with BV report no signs or symptoms at all.
How does bacterial vaginosis affect a pregnant woman and her baby?
Pregnant women with BV more often have babies who are born premature or
with low birth weight (low birth weight is less than 5.5 pounds).
The bacteria that cause BV can sometimes infect the uterus (womb) and
fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This
type of infection is called pelvic inflammatory disease (PID).
PID can cause infertility or damage the fallopian tubes enough to increase the
future risk of ectopic pregnancy and infertility.
Chlamydia35
Chlamydia is a common sexually transmitted infection (STI) caused by the
bacterium, chlamydia trachomatis, which can damage a woman's reproductive
organs. Even though symptoms of chlamydia are usually mild or absent, serious
complications that cause irreversible damage, including infertility, can occur
"silently" before a woman ever recognizes a problem. Chlamydia also can cause
discharge from the penis of an infected man.
What are the consequences of untreated Chlamydia?
If untreated, chlamydial infections can progress to serious reproductive and other
health problems with both short-term and long-term consequences. Like the disease
itself, the damage that chlamydia causes is often "silent."
Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
35 Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
34
46
In women, untreated infection can spread into the uterus or fallopian tubes
and cause PID.
Women infected with chlamydia are up to five times more likely to become
infected with HIV, if exposed.
Complications among men are rare.
Rarely, genital chlamydial infection can cause arthritis that can be
accompanied by skin lesions and inflammation of the eye and urethra
(Reiter's syndrome).
Genital human papillomavirus36, 37
Genital human papillomavirus (HPV) is the most common sexually transmitted
infection (STI). The virus infects the skin and mucous membranes. There are more
than 40 HPV types that can infect the genital areas of men and women, including the
skin of the penis, vulva (area outside the vagina), and anus, and the linings of the
vagina, cervix, and rectum. You cannot see HPV. Most people who become infected
with HPV do not even know they have it.
What are the symptoms and potential health consequences of HPV?
Most people with HPV do not develop symptoms or health problems. But
sometimes, certain types of HPV can cause genital warts in men and women. Other
HPV types can cause cervical cancer and other less common cancers, such as cancers
of the vulva, vagina, anus, and penis. The types of HPV that can cause genital warts
are not the same as the types that can cause cancer.
HPV types are often referred to as “low-risk” (wart-causing) or “high-risk” (cancercausing), based on whether they put a person at risk for cancer. In 90% of cases, the
body’s immune system clears the HPV infection naturally within two years. This is
true of both high-risk and low-risk types.
Genital warts usually appear as small bumps or groups of bumps, usually in the
genital area. They can be raised or flat, single or multiple, small or large, and
sometimes cauliflower shaped. They can appear on the vulva, in or around the
vagina or anus, on the cervix, and on the penis, scrotum, groin, or thigh. Warts may
appear within weeks or months after sexual contact with an infected person. Or,
they may not appear at all. If left untreated, genital warts may go away, remain
unchanged, or increase in size or number. They will not turn into cancer.
Cervical cancer does not have symptoms until it is quite advanced. For this reason, it
is important for women to get screened regularly for cervical cancer.
Other less common HPV-related cancers, such as cancers of the vulva, vagina, anus
and penis, also may not have signs or symptoms until they are advanced.
Source: HPV and Cervical Cancer. (2008). WHO: Geneva. Online document, available at:
http://www.who.int/vaccine_research/diseases/hpv/en/
37 Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
36
47
Genital herpes38
Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex
viruses type 1 (HSV-1) or type 2 (HSV-2). Most genital herpes is caused by HSV-2.
Most individuals have no or only minimal signs or symptoms from HSV-1 or HSV-2
infection. When signs do occur, they typically appear as one or more blisters on or
around the genitals or rectum. The blisters break, leaving tender ulcers (sores) that
may take two to four weeks to heal the first time they occur. Typically, another
outbreak can appear weeks or months after the first, but it almost always is less
severe and shorter than the first outbreak. Although the infection can stay in the
body indefinitely, the number of outbreaks tends to decrease over a period of years.
Gonorrhea39, 40
Gonorrhea is a sexually transmitted infection (STI). Gonorrhea is caused by
Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm,
moist areas of the reproductive tract, including the cervix (opening to the womb),
uterus (womb), and fallopian tubes (egg canals) in women, and in the urethra (urine
canal) in women and men. The bacterium can also grow in the mouth, throat, eyes,
and anus.
What are the signs and symptoms of Gonorrhea?
Some men with gonorrhea may have no symptoms at all. However, some men have
signs or symptoms that appear two to five days after infection; symptoms can take
as long as 30 days to appear. Symptoms and signs include a burning sensation when
urinating, or a white, yellow, or green discharge from the penis. Sometimes men
with gonorrhea get painful or swollen testicles.
In women, the symptoms of gonorrhea are often mild, but most women who are
infected have no symptoms. Even when a woman has symptoms, they can be so nonspecific as to be mistaken for a bladder or vaginal infection. The initial symptoms
and signs in women include a painful or burning sensation when urinating,
increased vaginal discharge, or vaginal bleeding between periods. Women with
gonorrhea are at risk of developing serious complications from the infection,
regardless of the presence or severity of symptoms.
Symptoms of rectal infection in both men and women may include discharge, anal
itching, soreness, bleeding, or painful bowel movements. Rectal infection also may
cause no symptoms. Infections in the throat may cause a sore throat but usually
causes no symptoms.
Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
39 Source: STD Statistics Worldwide. (2008). AVERT. Online document, available at:
http://www.avert.org/STIstatisticsworldwide.htm
40 Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
38
48
Pelvic inflammatory disease41
Pelvic inflammatory disease (PID) is a general term that refers to infection of the
uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the
uterus) and other reproductive organs. It is a common and serious complication of
some sexually transmitted infection (STIs), especially chlamydia and gonorrhea. PID
can damage the fallopian tubes and tissues in and near the uterus and ovaries. PID
can lead to serious consequences including infertility, ectopic pregnancy (a
pregnancy in the fallopian tube or elsewhere outside of the womb), abscess
formation, and chronic pelvic pain.
What are the signs and symptoms of PID?
Symptoms of PID vary from none to severe. When PID is caused by chlamydial
infection, a woman may experience mild symptoms or no symptoms at all, while
serious damage is being done to her reproductive organs. Because of vague
symptoms, PID goes unrecognized by women and their health care providers about
two thirds of the time. Women who have symptoms of PID most commonly have
lower abdominal pain. Other signs and symptoms include fever, unusual vaginal
discharge that may have a foul odor, painful intercourse, painful urination, irregular
menstrual bleeding, and pain in the right upper abdomen (rare).
Syphilis42
Syphilis is a sexually transmitted infection (STI) caused by the bacterium
Treponema pallidum. It has often been called “the great imitator” because so many
of the signs and symptoms are indistinguishable from those of other diseases.
What are the signs and symptoms of syphilis?
Many people infected with syphilis do not have any symptoms for years, yet remain
at risk for late complications if they are not treated. Although transmission occurs
from persons with sores who are in the primary or secondary stage, many of these
sores are unrecognized. Thus, transmission may occur from persons who are
unaware of their infection.
Primary Stage
The primary stage of syphilis is usually marked by the appearance of a single sore
(called a chancre), but there may be multiple sores. The time between infection with
syphilis and the start of the first symptom can range from 10 to 90 days (average 21
days). The chancre is usually firm, round, small, and painless. It appears at the spot
where syphilis entered the body. The chancre lasts 3 to 6 weeks, and it heals
without treatment. However, if adequate treatment is not administered, the
infection progresses to the secondary stage.
Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
42 Source: Sexually Transmitted infections: Fact Sheets. (2008). CDC: Atlanta. Online document,
available at: http://www.cdc.gov/std/healthcomm/fact_sheets.htm
41
49
Secondary Stage
Skin rash and mucous membrane lesions characterize the secondary stage. This
stage typically starts with the development of a rash on one or more areas of the
body. The rash usually does not cause itching. Rashes associated with secondary
syphilis can appear as the chancre is healing or several weeks after the chancre has
healed. The characteristic rash of secondary syphilis may appear as rough, red, or
reddish brown spots both on the palms of the hands and the bottoms of the feet.
However, rashes with a different appearance may occur on other parts of the body,
sometimes resembling rashes caused by other diseases. Sometimes rashes
associated with secondary syphilis are so faint that they are not noticed. In addition
to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands,
sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The
signs and symptoms of secondary syphilis will resolve with or without treatment,
but without treatment, the infection will progress to the latent and possibly late
stages of disease.
Late and Latent Stages
The latent (hidden) stage of syphilis begins when primary and secondary symptoms
disappear. Without treatment, the infected person will continue to have syphilis
even though there are no signs or symptoms; infection remains in the body. This
latent stage can last for years. The late stages of syphilis can develop in about 15%
of people who have not been treated for syphilis, and can appear 10 – 20 years after
infection was first acquired. In the late stages of syphilis, the disease may
subsequently damage the internal organs, including the brain, nerves, eyes, heart,
blood vessels, liver, bones, and joints. Signs and symptoms of the late stage of
syphilis include difficulty coordinating muscle movements, paralysis, numbness,
gradual blindness, and dementia. This damage may be serious enough to cause
death.
HIV and AIDS
HIV stands for human immunodeficiency virus. It is the virus that causes AIDS.43 A
member of a group of viruses called retroviruses44, HIV attacks the body's immune
system. By weakening the body's defences against disease, HIV makes the body
vulnerable to a number of potentially life-threatening infections and cancers. HIV is
infectious, which means it can be transmitted from one person to another.
AIDS stands for acquired immunodeficiency syndrome. It is a disease in which the
body's immune system breaks down and is unable to fight off infections, known as
"opportunistic infections," and other illnesses that take advantage of a weakened
immune system.
Source: The basics about HIV/AIDS. (2008). UNAIDS: Geneva. Online document, available at:
http://unworkplace.unaids.org/UNAIDS/basics/what_is_hiv.shtml
44 Source: Basic facts about HIV/AIDS. (2008). American Foundation for Aids Research.
43
50
When a person is infected with HIV, the virus enters the body and lives and
multiplies primarily in the white blood cells.45 These are immune cells that normally
protect us from disease. The hallmark of HIV infection is the progressive loss of a
specific type of immune cell called T-helper, or CD4, cells. As the virus grows, it
damages or kills these and other cells, weakening the immune system and leaving
the person vulnerable to various opportunistic infections and other illnesses
ranging from pneumonia to cancer. A person can receive a clinical diagnosis of AIDS,
if he or she has tested positive for HIV and meets one or both of these conditions:
The presence of one or more AIDS-related infections or illnesses;
A CD4 count that has reached or fallen below 200 cells per cubic millimeter
of blood. Also called the T-cell count, the CD4 count ranges from 450 to 1200
in healthy individuals.
HIV infects cells that are part of the body's immune system. As more cells are
infected by the virus, the immune system becomes less able to fight off disease.
To productively infect a cell, HIV must introduce its genetic material into the
interior of the cell. This process begins with attachment and entry of the virus,
uncoating of the virus membrane and integration of the virus genes into the human
gene. The human cell is hijacked to manufacture viral building blocks for multiple
copies that are subsequently assembled, eventually breaking out of the infected cell
in search of other cells to infect. The virus kills the cells it infects and also kills
uninfected bystander cells. The virus ensures that the human cell survives until its
own multiplication is completed. Even more damaging, HIV establishes stable
dormant forms that are reservoirs of infection that cannot be reached by currently
available drugs. These reservoirs make complete eradication-and a cure for AIDS-a
challenge.
Soon after HIV infection occurs, the body's immune system mounts an attack against
the virus by means of specialized killer cells and soluble proteins called antibodies
that usually succeed in temporarily lowering the amount of virus in the blood. HIV
still remains active, though, continuing to infect and kill vital cells of the immune
system. Over time, viral activity significantly increases, eventually overwhelming the
body's ability to fight off disease.
45
Ibid.
51
Strategies to Prevent and Treat STIs
The most comprehensive approach to managing STIs includes integration and
prevention and treatment of STIs within a package of reproductive services.46 For
instance, screening of pregnant women is an important aspect of antenatal care, as
STIs can be dangerous for both mothers and newborns.
Other key strategies to combat STIs include:
Condom promotion and distribution
Community-based advocacy on the dangers of STIs and ways to prevent them
Early diagnosis and treatment (of clients and their partners)
Providing specific services for populations at risk - such as long-distance
truck drivers, military personnel and prisoners
Source: Breaking the Cycle of Sexually Transmitted Infections. (2008). UNFPA: New York. Online
document, available at: http://www.unfpa.org/rh/stis.htm
46
52
Chapter V: Dual Protection
Objectives
To explain the concept of dual protection
To clarify who should use dual protection
To discuss how to facilitate dual protection use
Key Points
Dual Protection
Dual Protection is protection from both unplanned pregnancy and STI/HIV through
using one barrier contraceptive method such as the male of female condom.47, 48
A common misconception of dual protection is the use of two methods of
contraception at the same time with the belief that these will protect one from both
STIs and unintended pregnancy.
Who Needs Dual Protection?
Dual protection is needed by:
All heterosexually active people who wish to prevent unintended pregnancy
and HIV/STI, especially young people and those who are not in long term
relationships — a population group that accounts for over half of newly
acquired HIV infections and many unplanned pregnancies;
People having casual, short term, multiple or concurrent heterosexual
partnerships;
People who are having unsafe sex;
People who are infected with HIV or other STI and their partners;
Sexually active people in settings where STIs and/or HIV are highly
prevalent;
Sex workers and their clients of the opposite sex.
Prevention of Unwanted Pregnancy and STIs/HIV: The MAQ Exchange Curriculum. (2001).
Maximizing Access and Quality (MAQ) Initiative. Online document, available at:
http://www.maqweb.org/maqslides.shtml
48 Marshall, M. & Adjei-Sakyi, K. (2003). Female Condom and Dual Protection: Training for CommunityBased Distributors and Peer Educators. CDPA: Washington, DC.
47
53
Facilitating Dual Protection Use
The International Conference on Population and Development (ICPD), and the
recent review of progress made since that Conference (ICPD + 5), clearly identified
family planning and the prevention of HIV as major objectives. Putting dual
protection into practice to fulfil both of these objectives simultaneously requires
governments, international agencies, and reproductive health programmes, among
others, to ensure49:
Maximum integration of SRH50 and STI/HIV services;
The training and retraining of service providers and counsellors to ensure
provision of user-friendly, non-judgmental services, that enable clients to
make free, informed and individual decisions about dual protection;
Availability of condoms at many service delivery points and other outlets
including SRH, primary health care and NGO services;
The appropriate introduction of male and female condoms into reproductive
health programmes;
The incorporation of male and female condoms into programmes for the
prevention of mother-to-child transmission of HIV;
Continuing support for research on the development of a female-controlled
microbicide.
Overview
Research has clearly documented the effectiveness of male latex condoms both in
preventing unintended pregnancy and in providing a barrier to sexually transmitted
infections. If we just say bacteria and viruses, this is rather limiting. What about
protozoa such as Trachomonas Vaginalis and fungal infections such as Vaginal
Candiasis? I feel that it is more inclusive if we say STIs.
Condoms have long been the mainstay of HIV prevention. In 1999, a meta-analysis
of 25 studies found condoms to be 87–96% effective in preventing HIV transmission
between "discordant" couples, i.e. with one partner infected. It will be useful here to
add efficacy of the FC. What is more, women whose partners use condoms are at a
lower risk of hospitalization for pelvic inflammatory disease, a condition that can
result in infertility, than those whose partners do not use condoms.
Most heterosexual individuals who have sexual intercourse desire to protect
themselves from unintended pregnancy most of the time. Virtually all individuals all
of the time wish to avoid infections that can be sexually transmitted, particularly of
the most deadly and increasingly prevalent variety, the HIV infection. It is not
Source: Khanna, J. (Ed.). (2002). Dual Protection – Who Needs It and Why? Progress in Reproductive
Health. WHO. No. 59.
50 SRH services include family planning, antenatal care, obstetric, maternal and child health, and
adolescent health services
49
54
surprising therefore that people have started to ask: can both objectives be achieved
simultaneously?
Certainly, most family planning methods do not provide protection against infection.
And the methods available for infection prevention may not protect effectively
against unwanted pregnancy. Sterilization, intrauterine devices (IUDs), injectables,
implants and oral contraceptives, for example, provide no protection against
infection, and the protective efficacy of most existing female-controlled barrier
methods—caps, diaphragms, and foams or gels—is not as well proven as is the
protective effect of condoms against infection.
In fact, today, the condom is the only method that, when used correctly and
consistently, can at one and the same time effectively protect against both
pregnancy and infection.
Dual protection: Who needs it and why?
Family planning programmes have made considerable progress in providing
contraception to couples—witness the fact that nearly two-thirds of couples use
contraceptives today, up six-fold from the 1970s. However, sexually transmitted
infections (STIs) continue to spread rapidly throughout the world, especially in
developing countries. The spread of HIV certainly heightens the need for dual
protection, particularly in areas where HIV is prevalent and where women wishing
to adopt or continue using contraceptives would probably welcome a method that
protects them—and thereby their future offspring—against HIV. (Most HIVinfected children under ten have contracted the infection from their mothers).
In counselling their clients about the different methods of contraception,
reproductive health services should convey the fact that many methods (e.g.
hormonal methods of contraception, intrauterine devices, and sterilization),
although highly effective against pregnancy, offer no protection against STIs,
including HIV infection. By contrast, the condom, when used correctly and
consistently, not only prevents these infections but can also be an effective
contraceptive.
Governments and reproductive health programmes, both public and private, should
ensure that service providers and users understand how effective condoms are for
dual protection, so that they can provide the most useful and appropriate
information to their clients who are sexually active and at risk.
Dual protection is needed by:
sexually active people between the ages of 15 and 24—a population group
that accounts for over half of newly acquired HIV infections;
55
men and women who put their partners at risk because of their own risky
sexual behaviour or who are put at risk by the sexual behaviour of their
partners;
sexually active people in settings where STIs and/or HIV are highly
prevalent;
sex workers and their clients;
people who actually have an STI and/or HIV, and their partners.
Are we not repeating ourselves in the statements above?
The International Conference on Population and Development (ICPD), and the
recent review of progress made since that Conference (ICPD + 5), clearly identified
family planning and the prevention of HIV/AIDS as major objectives. Putting dual
protection into practice to fulfil both of these objectives simultaneously requires
governments, international agencies, and reproductive health programmes, among
others, to ensure: I don’t think that this repetition is necessary.
maximum integration of family planning and STI/HIV prevention services;
the training and retraining of service providers and counsellors to enable
clients to make free and informed decisions about dual protection;
availability of condoms at service delivery points and other outlets;
the appropriate introduction of female condoms into reproductive health
programmes;
the incorporation of dual protection into programmes for the prevention of
mother-to-child transmission of HIV;
continuing support for research on the development of a female-controlled
microbicide.
Condoms only effective if used correctly and consistently
The effectiveness of condoms, whether for single- or dual-purpose protection,
depends very much on how assiduously people, particularly men, use them. And
that depends on how highly they rate the importance and convenience of condoms
both as contraceptives and as barriers to infection, and in relation to other singlepurpose contraceptive methods.
A project involving six sub-Saharan African countries—Kenya, South Africa,
Tanzania, Uganda, Zambia, and Zimbabwe—has been probing the reasons why more
people do not use condoms more often for dual protection. The project involves a
total of 4000 men and women and uses focus group discussions, in-depth
interviews, and a survey questionnaire to explore their views.
Results from Kenya and South Africa have become available, showing in both
countries that a major obstacle to greater use of condoms is fear among potential
56
users of being perceived as having multiple partners and as being unfaithful to a
regular partner.
Other obstacles to condom use include opposition on religious grounds, male
dominance in decision-making, and women 's difficulty in convincing their partners
to use condoms. Not unexpectedly, women, who do appear to appreciate the gravity
of HIV infection and who say they do not have enough information about condoms,
turn increasingly to methods of protection against pregnancy, such as oral or
injectable contraceptives. These methods do not involve less confrontation with
their partners but unfortunately do not protect against infection. Confrontation may
still occur with use of oral and injectible contraceptives.
57
Chapter VI: Introducing the Male Condom
Objectives
To discuss the effectiveness of the male condom
To discuss guidelines for health promoters and service providers for
promoting condom use in their clients
To explain the proper use of the male condom
To answer frequently asked questions about male condoms
To discuss myths and misconceptions on male condoms
Key Points
Condom effectiveness
When correctly and consistently used, male and female condoms have been proved
to be more than 90% effective in preventing transmission of HIV and other STIs and
preventing pregnancy.51 52
Choosing a Condom
You should be aware that condoms vary in quality. Encourage your clients to check
the expiration date and buy them in retail outlets or pharmacies where the turnover
seems high or receive free condoms from trusted sources such as family planning
clinics. Remind your clients that they should also avoid storing condoms in places
where they will be exposed to heat, such as in a car glove compartment. When
opening the condom, make sure the package is intact and has no sign of external
dampness.
Some condoms are flavoured to make oral sex more enjoyable. Different sizes and
shapes are also available to ensure best fit and most pleasure for both partners.
Both free and store-bought condoms are available and they are of equal quality as
all condoms must undergo strict tests to ascertain quality. Please take note that this
last sentence negates what you say in the first sentence if the above paragraph.
Source: The Male Condom. (2000). UNAIDS Technical Update: Geneva.
Source: Living in a World with HIV/AIDS. (2004). UNAIDS. Online document, available at:
http://unworkplace.unaids.org/UNAIDS/basics/condoms/howto_male-condom.shtml
51
52
58
Overview
Condom effectiveness
An overwhelming body of evidence demonstrates that when properly used,
condoms are highly effective in preventing transmission of HIV and other STIs.53
Correct and consistent condom use should give you a high degree of confidence in
your ability to prevent HIV transmission.54
At least four different types of evidence demonstrate the effectiveness of condoms
in preventing HIV transmission.
Laboratory studies have shown that the virus cannot pass through latex or
polyurethane.
There is also a theoretical basis for effectiveness: condoms prevent exposure
to semen or vaginal fluids that may carry the virus.
Epidemiological studies, which compare infection rates among condom users
and non-users have found that condoms offer significant protection against
HIV infection.
Finally, in many countries that have significantly reduced HIV infection rates
(such as Brazil, Thailand and the USA), reduced rates of transmission have
been strongly associated with increased condom use.
When can condom fail?
No man-made prevention methods are 100% effective. Condoms rarely slip or
break.. Condoms that are outdated, poorly manufactured, or inappropriately stored
are especially susceptible to breakage. Oil-based products (such as hand lotion or
petroleum jelly) can also damage male latex condoms, so only water-based
lubricants should be used during sexual intercourse with a male condom.
In general, condoms are most likely to fail when they are not used as directed.
Opening a condom packet with your teeth, a knife or scissors, for example, can
inadvertently cause the condom to tear. Condoms must be used from the beginning
to the end of a sexual act. Putting on the condom only before ejaculation, makes one
susceptible to infections that may be in pre-ejaculate or vaginal fluids. Studies
suggest that the frequency of condom failure declines as individuals become more
accustomed to using condoms. That is one reason why effective HIV prevention
includes both accurate information on condoms and measures to increase individual
skills in using condoms correctly.
Source: The Male Condom. (2000). UNAIDS Technical Update: Geneva.
Source: Living in a World with HIV/AIDS. (2004). UNAIDS. Online document, available at:
http://unworkplace.unaids.org/UNAIDS/basics/condoms/howto_male-condom.shtml
53
54
59
In reality, condoms are extremely effective in preventing HIV transmission when
they are used consistently and correctly. Because sexual intercourse is often
unplanned, it is a good idea to always carry a condom in case you need one. If you
have a steady partner, you should also discuss how you as a couple intend to reduce
the risk of HIV transmission and to prevent pregnancies.
Ideally, a couple's decision to use a condom results from a process of negotiation.
The couple discusses the benefits of using a condom, addresses any concerns or
resistance, and agrees on a mutually satisfactory approach. Sometimes, though, one
member of the couple may lack the power to negotiate condom use. Many women,
for example, report having difficulty asking their husband or partner to use a
condom.
Why do I need to use a condom?55
Condoms are the only form of protection that can both help to (stop) significantly
reduce the transmission of sexually transmitted infections (STIs) such as HIV and
prevent pregnancy.
Getting ready, choosing the right condom
Both male and female condoms are now available. This section deals with the male
condom, which is a sheath or covering that fits over a man’s penis.
Add a diagram of the male condom.
What are condoms made of?
Condoms are usually made of latex or polyurethane.
Latex condoms can only be used with water based lubricants, not oil based
lubricants such as Vaseline or cold cream as they break down the latex.
A small number of people have an allergic reaction to latex and can use
polyurethane condoms instead. Polyurethane condoms are made of a type of
plastic. They are thinner than latex condoms, and so they increase sensitivity and
are more appealing in feel and appearance to some users. They are more expensive
than latex condoms and slightly less flexible so more lubrication may be needed.
However both oil and water based lubricants can be used with them. Currently
available female condoms are also made of polyurethane.
It is not clear whether latex or polyurethane condoms are stronger – there are
studies suggesting that either is less likely to break. With both types however, the
likelihood of breakages is very small if used correctly.
Source: Avert. Using Condoms, Condom Types and Sizes. (2004). Avert. Internet document, available
at: http://www.avert.org/usecond.htm
55
60
Lubricant
Most condoms are pre-lubricated with water-based or silicone lubricants by the
manufacturer. Some condoms are not lubricated at all. The lubrication aims to make
the condom easier to put on and more comfortable to use. If additional lubrication is
needed, water-based lubricants should be used with latex condoms. Both water
based oil based lubricants may be used with polyurethane condoms.
Lubricants can be used with or without condoms.56 But if used without condoms,
you have to remember that lubricants do not offer any protection against sexually
transmitted infections or HIV.
Spermicides and Nonoxynol 9
Condoms and lubricants sometimes contain a spermicide Adding spermicides to
condoms was thought in the past to help to prevent pregnancy and the transmission
of HIV and other STIs, but it is now known to be ineffective.
Some people have an allergic reaction to spermicide that can result in little sores,
which can actually make the transmission of HIV more likely. However, using a
condom (even if it contains spermicide) is much safer than having unprotected sex.
Is this last sentence adding any value?
What shapes are there and which should I choose? What about
flavoured condoms?
Condoms come in a variety of shapes. Most have a reservoir tip although some do
have a plain tip. Condoms may be regular shaped (with straight sides), form fit
(indented below the head of the penis), or they may be flared (wider over the head
of the penis).
Ribbed condoms are textured with ribs or bumps, which can increase sensation for
both partners. Condoms also come in a variety of colours.
It Is up to you which shape you choose. All of the differences in shape are designed
to suit different personal preferences and enhance pleasure. It is important to
communicate with your partner to be sure that you are using condoms that satisfy
both of you.
Choosing a condom
Condoms are made in different lengths and widths, and different manufacturers
produce varying sizes.
Source: Lubricants. (2008). AVERT. Online document, available at: http://www.avert.org/aidspicture.php?photo_id=499
56
61
There is no standard length for condoms, though those made from natural rubber
will in addition always stretch if necessary to fit the length of the man's erect penis.
The width of a condom can also vary. Some condoms have a slightly smaller width to
give a "closer" fit, whereas others will be slightly larger. Condom makers have
realised that different lengths and widths are needed and are increasingly
broadening their range of sizes.
Some condoms are flavoured to make oral sex more enjoyable.
The brand names will be different in each country, so you will need to do your own
investigation of different names. There is no particular best brand of condom. Also,
free and store-bought condoms are of same quality, as they all must undergo
rigorous tests.
Where can I get condoms?
There are no age limitations on buying condoms. Buying or taking condoms from
places that are providing them for free no matter how old you are shows that you
are taking responsibility for your actions. Athough this is what is desirable, the
scenario may be different from country to country. Family planning and sexual health
clinics provide condoms free of charge. Condoms are available from supermarkets,
convenience stores and petrol/gas stations, vending machines. You can also order
then online from different manufacturers and distributors.
So when do you use a condom?
You need to use a new condom every time you have sexual intercourse. Never use
the same condom twice. Put the condom on after the penis is erect and before any
contact is made between the penis and any part of the partner's body. If you go from
anal intercourse to vaginal intercourse, you should consider changing the condom.
How can I check a condom is safe to use?
Condoms that have been properly tested and approved carry the British Standard
Kite Mark or the EEC Standard Mark (CE). Not necessarily true all the time. Countries
may have their own quality assurance testing done by their regulatory authorities
based on WHO standards. Countries recognise and respect WHO standards more than
the Kite Mark, EEC or FDA etc. It would therefore be wise to say, where country specific
quality assuarance does not exist, then these other standards may be used. In the USA,
condoms should be FDA approved, and elsewhere in the world, they should be ISO
approved. To find out more about condom testing see our Condoms history,
effectiveness and testing page.
Condoms should have an expiration (Exp) or manufacture (MFG) date on the box or
individual package that tells you when it is safe to use the condom until. It's
62
important to check this when you use a condom. You should also make sure the
package and the condom appear to be in good condition.
Condoms can deteriorate if not stored properly as they are affected by both heat and
light. So it's best not to use a condom that has been stored in your back pocket, your
wallet, or the glove compartment of your car. If a condom feels sticky or very dry
you shouldn't use it as the packaging has probably been damaged. In case the date
of expiration is not written, keep in mind that the male condom is good for
approximately three years from date of manufacture.
How do you use a condom?
1. Open the condom package at one corner being careful not to tear the condom
with your fingernails, your teeth, or through being too rough. Make sure the
package and condom appear to be in good condition, and check that if there
is an expiry date that the date has not passed.
2. ?Make sure the condom is on the right size. Kindly clarify
3. The condom should unroll smoothly and easily from the rim on the outside. If
you have to struggle or if it takes more than a few seconds, it probably means
that you are trying to put the condom on upside down. To take off the
condom, don't try to roll it back up. Hold it near the rim and slide it off. Then
start again with a new condom.
4. Place the rolled condom over the tip of the erect (hard) penis, and if the
condom does not have a reservoir top, pinch the tip of the condom enough to
leave a half inch space for semen to collect. If the man is not circumcised,
then pull back the foreskin before rolling on the condom.
5. Pinch the air out of the condom tip with one hand and unroll the condom
over the penis with the other hand. Roll the condom all the way down to the
base of the penis, and smooth out any air bubbles. (Air bubbles can cause a
condom to break.)
6. If the condom breaks during sexual intercourse, then pull out quickly, rinse
and replace the condom. ?Whilst you are having sex, check the condom from
time to time, to make sure it hasn't split or slipped off. If the condom has
broken and you feel that semen has come out of the condom during sex, you
should consider getting emergency contraception to avoid unintended
pregnancy and an HIV test.
7. If you want to use some extra lubrication, put it on the outside of the condom.
But always use a water-based lubricant with latex condoms, as an oil-based
lubricant will cause the latex to break.
8. Remove the condom immediately after ejaculation, Pull out before the penis
softens, and hold the condom against the base of the penis while you pull out,
so that the semen doesn't spill. Condom should be disposed properly for
example wrapping it in a tissue and throwing it away. It's not good to flush
condoms down the toilet - they're bad for the environment.
63
The man wearing the condom doesn't always have to be the one putting it on - it can
be quite a nice thing for his partner to do.
Insert graphic
What condoms should you use for anal intercourse?
With anal intercourse more strain is placed on the condom. You can use stronger
condoms (which are thicker) but standard condoms are just as effective as long as
they are used correctly with plenty of lubricant. Condoms with a lubricant
containing spermicide should NOT be used for anal sex as spermicide damages the
lining of the rectum increasing the risk of HIV and other STI transmission.
Reasons to Use Condoms
Condoms are the only contraceptive that help prevent both pregnancy and
the spread of sexually transmitted infections (including HIV) when used
properly and consistently.
Condoms are one of the most reliable methods of birth control when use
properly and consistently.
Condoms have none of the medical side-effects of some other birth control
methods may have.
Condoms are available in various shapes, colours, flavours, textures and sizes
- to increase the fun of making love with condoms.
Condoms are widely available in pharmacies, supermarkets and convenience
stores. You don't need a prescription or have to visit a doctor.
Condoms make sex less messy.
Condoms are user friendly. With a little practice, they can also add
confidence to the enjoyment of sex.
Condoms are only needed when you are having sex unlike some other
contraceptives which require you to take or have them all of the time.
Here are also some tips that can help you to feel more confident and relaxed
about using condoms.
How can I persuade my partner that we should use a condom?
It can be difficult to talk about using condoms. But you shouldn't let embarrassment
become a health risk. The person you are thinking about having sex with may not
agree at first when you say that you want to use a condom when you have sex. These
are some comments that might be made and some answers that you could try...
EXCUSE
ANSWER
Don't you trust me?
Trust isn't the point, people can have
infections without realising it
64
It does not feel as good with a condom
I'll feel more relaxed, If I am more relaxed, I
can make it feel better for you.
I don't stay hard when I put on a condom
I'll help you put it on, that will help you
keep it hard.
I am afraid to ask him to use a condom.
He'll think I don't trust him.
If you can't ask him, you probably don't
trust him.
I can't feel a thing when I wear a condom
Maybe that way you'll last even longer and
that will make up for it
I don't have a condom with me
I do
It's up to him... it's his decision
It's your health. It should be your decision
too!
I'm on the pill, you don't need a condom
I'd like to use it anyway. It will help to
protect us from infections we may not
realise we have.
It just isn't as sensitive and I can't feel a
thing
Maybe that way you will last even longer
and that will make up for it
You repeated this one
Putting it on interrupts everything
Not if I help put it on
I guess you don't really love me
I do, but I am not risking my future to
prove it
I will pull out in time
Women can get pregnant and get STIs from
pre-ejaculate
But I love you
Then you'll help us to protect ourselves.
Just this once
Once is all it takes
There are many reasons to use condoms when having sex. You could go through
these reasons with your partner and see what she/he thinks.
Confidence tips
Keep condoms handy at all times. If things start getting steamy - you'll be
ready. It's not a good idea to find yourself having to rush out at the crucial
moment to buy condoms - at the height of the passion you may not want to.
65
When you buy condoms, don't get embarrassed. If anything, be proud. It
shows that you are responsible and confident and when the time comes it
will all be worthwhile. It can be more fun to go shopping for condoms with
your partner or friend. Nowadays, it is also easy to buy condoms discreetly
on the internet.
Talk with your partner about using a condom before having sex. It removes
anxiety and embarrassment. Knowing where you both stand before the
passion stands will make you lot more confident that you both agree and are
happy about using a condom.
If you are new to condoms, the best way to learn how to use them is to
practice putting them on by yourself or your partner. It does not take long to
become a master.
If you feel that condoms interrupt your passion then try introducing
condoms into your lovemaking. It can be really sexy if your partner helps you
put it on or you do it together.
Crucial Guidelines for Health Promoters and Service Providers57
57
Present condoms as an effective technology to prevent unintended
pregnancy and sexual transmission of HIV and other STIs as part of a wider
HIV/STI prevention strategy that also includes promoting: delaying first
sexual experience, abstinence from penetrative sex, and mutual fidelity
between sexual partners.
Challenge gender norms that reinforce inequalities, particularly regarding
condom use, and seek ways to empower women to have a stronger voice in
their own reproductive health.
Debunk myths, correct misperceptions, and calm fears. This requires health
promoters and service providers to:
o Understand the people you are working with and their varied cultural
beliefs.
o Help people gain new insights and knowledge.
o Convey the effectiveness of condoms for the prevention of infection
and unintended pregnancy.
Adopt acceptable language to discuss sexuality and condom use effectively
with potential users.
Create open attitudes about condoms and other sexual issues to help people
communicate effectively with their partners.
Respect people’s level of awareness and help them balance their biases with
the benefits of condom use, so that people accept condom use as a
widespread social norm, practiced by influential peers and role models.
Be aware of socio-cultural influences, and engage community, religious, and
political leaders in creating a supportive environment for condom
promotion.
Source: Myths, Misperceptions and Fears Addressing Condom Use Barriers. (2007). IPPF & UNFPA.
66
Use teaching/learning tools, such as demonstration models, that are as close
to reality as possible.
Use humour when talking about condom use
Present condoms as a dual protector
67
Chapter VII: Introducing the Female Condom
Objectives
To introduce the female condom
To explain the proper usage of the female condom
To show differences between a female condom and a male condom
To present strategies for explaining the female condom to potential users
Key Points
Introducing the Female Condom
The female condom is a strong, soft, transparent polyurethane sheath inserted in
the vagina before sexual intercourse, providing dual protection against both
pregnancy and STIs including HIV. It forms a barrier between the penis and the
vagina, cervix and external genitalia. It is stronger than latex, odourless, causes no
allergic reactions, and, unlike latex, may be used with both oil-based and waterbased lubricants. It can be inserted prior to intercourse, is not dependent on the
male erection, and does not require immediate withdrawal after ejaculation. The
female condom has no known side-effects or risks.58
By removing the inner ring in the female condom, one may also use the product for
anal intercourse for male or female receptive partners.59, 60 Is this what the
manufacturer says? If not should we be saying this as UNFPA? I think we could
rephrase this as: Some people remove the inner ring in the FC and use the condom
for anal intercourse.
The female condom provides dual protection for preventing pregnancy and STIs,
which, based on laboratory studies, should include HIV.
The female condom is a relatively recent development, but its use is increasing, with
studies showing that it the female condom is acceptable to both male and female
partners.
58
Source: The Female Condom: A guide for planning and programming. (2000). WHO & UNAIDS.
68
It is usually more expensive than the male condom and is not as readily available for
purchase in many parts of the world. However in most developing countries where
it is available, governments and other NGOs provide them free of charge or at a
subsidised price.
In 2005 the makers of the FC female condom announced a new product called FC2.
This has the same design as the original version but is made of nitrile, which may
make it cheaper to produce. The FC2 began large-scale production in 2007. The
United Nations Population Fund (UNFPA) is already procuring the FC2. The FDA
approved the FC2 in December 2008 and the World Health Organisation has stated
that the product is acceptable for bulk procurement by UN agencies61. Bidia, how
best do we put this across, considering the ongoing process?
Source: Female Condom. (2009). Internet document, available at:
http://www.fda.gov/cdrh/panel/summary/obgyn-121108.html
61
69
Overview
Details of the Female Condom62
The Female Condom
A strong loose-fitting polyurethane sheath that is 17 cm long (about 6.5 inches) with
flexible ring at each end
Polyurethane is a soft, thin plastic that is stronger than latex, which is used to make
most male condoms.
Polyurethane conducts heat, so sex with the female condom can feel very sensitive
and natural.
Polyurethane is odorless.
The inner ring is used to insert the female condom and helps keep the female
condom in place. The inner ring slides in place behind the pubic bone.
The outer ring is soft and remains on the outside of the vagina during sexual
intercourse. It covers the area around the opening of the vagina (the vulva). It can
provide pleasurable for men and women.
Protects the vagina, cervix, and external genitalia, affording extensive barrier
protection.
There are no serious side-effects associated with use of the female condom, and less
than 10% of users report mild irritations.
Polyurethane is less kikely to cause allergic reactions.
It can be inserted ahead of time so it will not interrupt sexual spontaneity.
It comes pre-lubricated with a non-spermicidal, silicone-based lubricant that is
needed for ease of insertion and for easy movement during intercourse.
Lubrication reduces noise during sexual intercourse and makes sex smoother.
Additional lubricant can be used, and you can use both oil-based and water-based
lubricants.
It is not tight or constricting.
It does not require a prescription or the intervention of a healthcare provider.
The Female Condom and Gender Equality63
The female condom is a way of addressing gender inequalities that are a major
obstacle in HIV prevention. The female condom provides the opportunity for women
to actively protect themselves from HIV infection. It is a method they can choose and
initiate. It enables them to be in a position where they learn about their
reproductive health in general, which is an important building block in HIV
prevention. When women can protect themselves from HIV infection, they have an
Female Condom. (2007). Femalehealth Co. Internet document, available at:
http://www.femalehealth.com/Product%20FC%20Details1.htm
62
70
increased sense of self-worth. This could prove to be one of the most important
elements in fighting the AIDS epidemic.
How to use the Female Condom
This is a female condom. It has a ring at each end.
The first step is to pinch the 'inner' ring so that you can insert it, a bit like one
does with a diaphragm. At the closed end of the sheath, the flexible ring is
inserted into the vagina to hold the female condom in place. At the other
open end of the sheath, the ring stays outside the vulva at the entrance to the
vagina. This ring acts as a guide during penetration and it also stops the
sheath bunching up inside the vagina.
Next, insert the female condom into the vagina (or anus, minus the inner
ring). Once again, this is done much in the same way that a woman might use
a tampon or diaphragm.
Push the female condom up into the vagina so that the inner ring is round the
cervix. The natural shape of the vagina generally holds it in place. Remember
that the female condom can be inserted up to 8 hours before you have sex.
It is now safe to have penetrative sex. Be sure that the penis goes inside the
female condom and not between the outside of the female condom and the
wall of the vagina. In this way, the surface of the genitals of the male and the
female are protected.
After sexual intercourse, twist the female condom and then pull to remove.
Dispose of it in a responsible and appropriate manner, remembering the '3
Bs': bin, burn or bury. Never flush it down the toilet, as it will block the
plumbing system. The condom may also be thrown in a pit latrine
Insert graphic
Comparison between a female condom and a male condom64
Both the female condom and male condom are barrier methods that provide dual
protection against pregnancy and STIs.The male latex condom has been proven to
protect against HIV/AIDS. Although no clinical studies of the female condom for HIV
prevention have been conducted, laboratory studies indicate that the female
condom is impermeable to STIs and HIV. The female condom is the same length as
the male condom and somewhat wider. They also differ in the following ways:
64
Source: The Female Condom: A guide for planning and programming. (2000). WHO & UNAIDS.
71
Male Condom
Female Condom
Rolled on the man’s penis
Inserted into the woman’s vagina
Made from latex;some also from
Made from polyurethane
polyurethane
Loosely lines the vagina
Fits on the penis
Lubricant:
Lubricant:
Can include spermicide
o
Can be water-based or oil-based
o
Can be water-based only;cannot
be oil-based
o
Located on the inside of condom
o
Located on the outside of condom
Requires erect penis
Condom must be put on an erect
penis
Must be removed immediately after
ejaculation
Does not require erect penis
Can be inserted prior to sexual
intercourse, not dependent on erect
penis
Covers most of the penis and
genitalia
Latex condoms can decay if not
product
Polyurethane is not susceptible to
deterioration from temperature or
humidity
Recommended as one-time use
Covers both the woman’s internal
and external genitalia and the base of
the penis
stored properly;
Does not need to be removed
immediately after ejaculation
protects the woman’s internal
Can include spermicide
o
o
Recommended as one time use
product. Re-use research is
currently underway. Is it, still?
Explaining the female condom to potential users
The female condom is the first and only female-controlled contraceptive barrier
method with the advantage of also providing protection from STIs. The female
72
condom is safe and effective if used correctly and consistently and has high
acceptability among both women and men in many countries. Because it is a new
method, though, the way the product is presented to potential users is critical. Many
people will be seeing the female condom for the first time and, at first glance, the
female condom may look strange or hard to use.
Introducing the female condom can be done in groups or in one-to-one sessions.
Group sessions offer a friendly environment where women (and/or men) can share
information, ideas and experiences. In one-to-one sessions, messages can be tailored
to fit the specific needs of a user. In either case, the following are essential
ingredients to successful introduction:
Humour
Maintaining a non-judgmental attitude
Covering basic concepts
Using plain language
Encouraging interaction
The following is an outline of the way the female condom can be introduced. It is
meant to be adapted and modified depending on the setting.
1. Describe the social context of HIV/AIDS and STIs in the community/country
and dynamics of sexual relationships.
2. Establish how much the person or group knows about safer sex, anatomy and
the female condom.
3. Provide a brief overview of disease transmission.
4. Provide an overview of the reproductive system.
5. Discuss personal vulnerability and risk.
6. Explain protection, especially the idea of “dual protection”– protection from
STIs/HIV/AIDS and unintended pregnancy.
7. Highlight major anatomy points that relate to the female condom:
The difference between the vaginal canal and the urethra.
The vagina is a closed pouch.
The location of the pubic bone and cervix.
Explain that the female condom will not interfere with normal bodily
functions.
Explain that the FC is inserted into a woman’s vagina and will not get
lost into the womb
8. Let each person touch the female condom.
73
Chapter VIII: Reproductive Health Commodity Security
Objectives
To define the concept of Reproductive Health Commodity Security
To identify 6 rights related to Reproductive Health Commodity Security
To explain the systems approach to achieving Reproductive Health
Commodity Security
Key Points
Reproductive Health Commodity Security
Reproductive Health Commodity Security (RHCS) strategy aims to let women and
men everywhere obtain and use the reproductive health supplies of their choice
whenever they need them.65
We can educate, inform and motivate individuals to choose healthier behaviours,
but we are failing them if the basic supplies they need to protect their health and
their reproductive choices are not constantly available to them.
Protecting reproductive health requires sustained, uninterrupted access to
contraceptives, condoms and other medical supplies. Yet millions of women and
men in developing countries go without these essentials, leaving them vulnerable to
reproductive health problems.66
Essential Supplies Save Lives67
6 Rights
Securing the supply of reproductive health essentials is more complicated than it
may seem. It requires systems to get everything right: the right quantities of the
right products in the right condition in the right place at the right time for the right
price. These six rights add up to one more: the fundamental human right to
reproductive health care.68
Adapted from: Securing the Supplies People Rely On. (2004). UNFPA: New York.
Ibid.
67 Source: Global Estimates of Contraceptive Commodities and Condoms for STI/HIV Prevention.
(2002). UNFPA, New York.
68 Adapted from: Securing the Supplies People Rely On. (2004). UNFPA: New York.
65
66
74
Systems Approach
Achieving RHCS cannot be accomplished by one agency. A multi-agency, multisectoral approach, establishing a secure, functioning system is required for
achievement of results. Each partner is asked to use its particular competitive
advantage in a coordinated and systematic joint effort to ensure a steady and
reliable flow of reproductive health essentials. Activities should reflect the CCP
Framework domains:
o Leadership and coordination
o Supply and commodity security
o Demand, access, and utilization
o Support
Overview
The last 40 years have seen tremendous improvements in the reproductive health
(RH) of men and women in low- and middle-income (LMI) countries. In that time,
contraceptive prevalence rates have risen from an average of around 10% to over
60%. The number of LMI countries with official population policies has grown from
2 to 115, while total fertility rates have dropped from 6 to 2.69
Unfortunately, these achievements are under threat today. And they are under
threat because many in the developing world can no longer access the basic RH
supplies and commodities including condoms they need, whether it is to prevent
unwanted pregnancies, ensure safe deliveries, or prevent, manage and treat sexually
transmitted infections.
In the next 10 years, the number of contraceptive users is projected to increase by
more than 21%.70 Without a reliable supply of sexual and RH commodities,
including male and female condoms and quality service provision, the promises
made at the International Conference on Population and Development (ICPD), the
Millennium Summit, and reiterated at the September 2005 World Summit cannot
and will not be kept.
Source: About Reproductive Health Supplies. (2008). Reproductive Health Supplies Coalition. Online
document, available at: http://www.rhsupplies.org/about_rh_supplies.html
70 Source: About Reproductive Health Supplies. (2008). Reproductive Health Supplies Coalition. Online
document, available at: http://www.rhsupplies.org/about_rh_supplies.html
69
75
What are reproductive health supplies?
In principle, the term “RH supplies” refers to any medicines, material or consumable
needed to provide reproductive health (RH) services. This includes, but is not
necessarily limited to contraceptives for family planning, male and female condoms,
drugs to treat sexually transmitted infections, and equipment such as that used for
safe delivery.
What is Reproductive Health Commodity Security71
RHCS is achieved when all individuals can obtain and use affordable, quality
reproductive health commodities of their choice whenever they need them,
including male and female condoms.
Reproductive Health Commodity Security Strategy
One of the critical components underpinning any comprehensive condom
programming strategy is Reproductive Health Commodity Security (RHCS)—a state
in which all individuals can obtain and use affordable, quality RH commodities of
their choice whenever they need them. RHCS is not only a basic human right, as
established in the ICPD and MDG frameworks but also critical to improving related
health outcomes, such as maternal health and HIV prevention. Some estimates
indicate that, by preventing pregnancies and unsafe abortions, family planning
commodities alone, including condoms, can reduce maternal deaths by 20-35%,
which equates to saving at least 100,000 women’s lives each year. RH commodities,
including condoms, play integral roles not only before pregnancy but also during
pregnancy and childbirth. Most antenatal services, delivery and post-partum care
and emergency obstetric care could not be delivered effectively and safely without
appropriate RH commodities in the right place and at the right time. When RHCS is
achieved, along with complementary improvements in the health system, these
evidence-based services improve maternal health, reduce maternal mortality and
boost newborn survival. RHCS is critical to successful HIV prevention strategies and
programmes by enabling the provision and utilization of HIV test kits and
diagnostics and by improving the overall supply chain and logistics management
information system. Male and female condoms, which can reduce risk of STIs,
including HIV, are another case in point. Experience has shown that access to simple
messages and training on RH and HIV prevention, together with availability of RH
commodities, including male and female condoms, can have a significant impact on
women’s health as well as the livelihoods of households in general.
The inextricable link between RHCS and HIV necessitates integration of HIV and RH
programmes at country level. For condoms—a critical cornerstone of RHCS and HIV
prevention strategies—such as integration is facilitated through Comprehensive
Condom Programming (please see the chapter on CCP for the overview of the
71
Source: Reproductive Health Commodity Security: 2007 Progress Report. (2007). UNFPA: New York.
76
framework), a management and social marketing concept that focuses on all aspects
of supply and demand of male and female condoms.
What is the problem?72
Worldwide, the availability of reproductive health (RH) supplies, including
contraceptives, medicines for prevention and treatment of sexually transmitted
infections and HIV/AIDS, and medicines to ensure healthy pregnancy and delivery,
falls short of current demands. No single set of factors can fully explain this reality.
But the following three factors have been identified:
Inadequate or insufficient resources to meet increasing demand
Weak systems amidst an increasingly complex supply environment
Lack of global coordination and information sharing
Inadequate or insufficient resources to meet increasing demand
Due to the successes of family planning programmes and the growing number of
men and women of reproductive age, the demand for reproductive health (RH)
supplies is greater than ever. The funds needed to purchase them are expected to
increase from approximately US$ 1.8 billion in 2000 to US$ 3.4 billion in 2015.
Historically, international development assistance has accounted for approximately
20 percent of the total market worldwide for RH supplies. But that percentage has
been falling – especially so in the case of family planning which, since 2000, has seen
a decline of 39 percent relative to spending for other areas of population assistance.
Ensuring adequate donor resources is critical to meeting the supply challenge.
Accessing those resources once they arrive is equally critical – and often equally
precarious. The trend towards greater country ownership of the development
process has shifted the responsibility for financing supplies to countries themselves.
Unfortunately, the national players needed to complete this transition are not
always on board. Many countries with funds that could be used to guarantee supply
security are instead allocated elsewhere. Many of these countries lack national
budget lines for supplies; and many of those with line items still see unspent funds.
Household resources represent yet another often underexploited opportunity to
narrow the supply gap. For those who can afford to do so, purchasing goods and
services outside the public sector frees up scarce funds for those who do not have
the means to do so. Unfortunately, the potential role of the marketplace and private
sector generally is often undermined by indifference or, at worst, punitive policies
and practices. The imposition of heavy tax barriers, the application of complex
regulatory requirements, and the occasional widespread release of free
commodities all undermine the “total market” and the flow of household resources.
Source: About Reproductive Health Supplies. (2008). Reproductive Health Supplies Coalition. Online
document, available at: http://www.rhsupplies.org/about_rh_supplies.html
72
77
Weak systems amidst an increasingly complex supply environment
The shift towards greater country ownership of the development process brings
with it tremendous responsibilities. With fewer donors taking an active role in
addressing reproductive health (RH) supply needs, that responsibility has now
increasingly shifted to the countries themselves. This requires the presence of
functional, effective systems for forecasting, procuring, warehousing, distributing,
and managing information.
Confronting this new environment is a challenge. The legacy of vertical assistance
programmes have left many countries ill equipped to bear the new responsibilities
placed on them. It has, in many cases, left them with tools and systems that are
duplicative, wasteful, and counterproductive to the development of national health
systems.
The environment countries face is itself becoming more complex. The number and
types of organizations involved in procuring and distributing RH supplies have
grown dramatically over the last 15 years. While in the early 1990s only about three
donors were involved in procuring contraceptives, now there are more than ten,
each with different procurement rules and supply sources. Added to this is a
proliferation in the number of manufacturers, including “generic manufacturers”
emerging throughout the developing world. Managing this new environment
requires efficient, effective systems that allow countries to procure high-quality
supplies and deliver them efficiently in a timely manner.
Finally, the last few decades have seen considerable divergence with respect to the
development process. Some countries have matured to a more developed status,
while others are still struggling with key systems issues. And cutting across all are
areas affected by conflict, natural disasters, and other crises. The level of RH
commodity security among these different categories of countries varies, and
responses must be tailored accordingly and by donors and agencies charged with
responding to emergencies.
Lack of global coordination and information sharing
Supply security is undermined both by resource shortfalls and by failing to make the
most – through inefficiency, inaction, or duplication – of the resources that do exist.
Though countries have a key role to play in addressing these challenges, all too often
the solutions require global action. Calls to harmonize tools, apply universal quality
standards, or adopt best practices are futile if the global community is not on board
or cannot take common action when common action is required.
Another facet of the supply challenge is the diminishing priority of reproductive
health (RH) relative to other health concerns and other disease-specific
partnerships. The huge increases in funding for HIV/AIDS in particular have set up a
competitive environment, one in which RH managers have not been especially
successful or active in budgeting, advocating for, and securing the human and
financial resources needed for their programmes. At the same time, recognition of
78
the value and importance of working together with other health partnerships on
issues of supplies, both globally and at country level, is growing.
Political sensitivities surrounding RH are yet another barrier challenging RH supply
security. Conservative opposition to family planning and the principles of
the International Conference on Population and Development (ICPD) is not limited
to any one country or region. Giving high priority to RH in these circumstances,
therefore, requires significant political will and continuous advocacy on a global
scale.
Supply Chain Essentials73
A successful health care program delivers consistent, high-quality, cost-effective
services. Often, when a program is being designed, an essential component is often
overlooked—the logistics system. A carefully planned, well-functioning logistics
system can ensure a dependable supply of health care products for the clients who
need them. When a health facility is fully stocked with a wide range of contraceptive
methods and essential drugs, clients gain confidence in that facility and they are
more likely to return.
For example, if women were given reliable access to the full range of contraceptives,
it is possible to prevent one of every four deaths related to pregnancy in the
developing world. Women without reliable access to reproductive health care and
commodities, including male and female condoms, face an increased risk of birth
complications, unintended or mistimed pregnancies, unsafe abortions, infectious
diseases, and even death.
Commodities for HIV/AIDS and malaria treatment are two examples of how efficient
logistics systems can save lives. A dependable supply of HIV/AIDS commodities,
including male and female condoms at service delivery points determines the
success of antiretroviral (ARV) treatment programs; supply interruptions introduce
the risk of drug resistance, which can develop when HIV replication is not fully
suppressed. In the case of malaria, drugs must be given soon after the onset of
malaria-caused fever. If the appropriate drugs are available, many lives can be
saved.
Even though it is behind-the-scenes, a strong logistics system will help create a
successful health program on many levels. For example, a weak logistics system can
cause stockouts of critical products, leaving clients underserved, or a facility may be
overstocked with expired products—a waste of scarce resources. The danger is that
a logistics system’s crucial functions can go unnoticed by policymakers and program
managers until the system fails to deliver.
Source: Supply Chain Essentials. (2008). USAID & John Snow. Online document, available at:
http://deliver.jsi.com/dhome/topics/supplychain
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79
A reliable, responsive logistics system makes the difference between a client
consistently receiving the product he or she needs—condoms, vaccines, and other
drugs—or a client walking away empty-handed. The success of your health care
program depends on the strength of your system.
80
Chapter IX: Risk Assessment and Behaviour Change
Objectives
To examine personal values about condom use, HIV and SRHR (including
STIs)
To review techniques of assessing the client’s risk of HIV infection, STIs (and
unintended pregnancies)
To review techniques of assessing the client’s perceptions of his/her risk of
HIV infection, STIs (and unintended pregnancies)
To learn how to assist clients to create a risk reduction plan
To help promote behaviour change
To present a method for clients’ HIV and STI self screening (and ‘recognising
pregnancy’?)
Key Points
Personal values and attitudes influence both clients’ willingness towards safer
sexual behaviours and service providers’ ability to assist clients in making those
changes.
HIV and STI risk assessment is an ongoing process, not a one-time clinical
intervention.74 Assessments can assist providers in: 1) Knowing when to offer
voluntary HIV testing and counselling, identifying women who are infected with
HIV, yet unaware of their status and thus not receiving care; 2). Please take note that
VCT implies people deciding on their to visit a testing and counselling centre. Once a
service provider offers testing and counselling, it is no longer VCT, but provider
initiated testing and counselling (PITC) or routine offer of testing and counselling..
Providing routine screening for sexually transmitted infections; and 3) Providing
clinicians the opportunity to specifically target, introduce and/or reinforce safer sex
messages.
Frank, L. et al. (2006). HIV Case Finding and Secondary Prevention for Women: Clinical Risk
Assessment and Screening Guide A Reference Tool for Clinicians. Pennsylvania/MidAtlantic AETC.
74
81
Overview
Values
Values represent what a person appreciates and esteems. If young people have
learned to practice safer sex, for example, they will be more likely to delay having
sex or to practice safer sex.75
Beliefs
Beliefs are the things we believe to be true, even if we cannot prove them. For
example, belief in God / Allah, or the Buddha, or belief in ghosts, or belief that our
ancestors are watching over us, or belief in lucky numbers or auspicious days.
Beliefs are more about thoughts or ideas than feelings.
Attitudes
Attitudes are a person’s feelings towards something or someone. In the context of
lets have our context as comprehensive condom programme. SRHR, HIV and AIDS,
tolerance of different lifestyles, rejection of discrimination and prejudice, as well as
compassion and care, are very important attitudes.
Stigma and Discrimination
Because of its association with behaviours that may be considered socially
unacceptable by many people, HIV infection is widely stigmatised.76
People living with the virus are frequently subject to discrimination and human
rights abuses: many have been thrown out of jobs and homes, rejected by family and
friends, and some have even been killed.
Together, stigma and discrimination constitute one of the greatest barriers to
dealing effectively with the epidemic. They discourage governments from
acknowledging or taking timely action against AIDS. They deter individuals from
finding out about their HIV status.
And they inhibit those who know they are infected from sharing their diagnosis and
taking action to protect others and from seeking treatment and care for themselves.
Experience teaches that a strong movement of people living with HIV that affords
mutual support and a voice at local and national levels is particularly effective in
Source: Y-PEER Training of Trainers Manual. (2006). UNFPA & FHI: New York. Internet document,
available at: http://www.unfpa.org/adolescents/docs/ypeer_tot.pdf
76 Source: Stigma and discrimination. (2008). UNAIDS. Internet document, available at:
http://www.unaids.org/en/PolicyAndPractice/StigmaDiscrim/default.asp
75
82
tackling stigma. Moreover, the presence of treatment makes this task easier too:
where there is hope, people are less afraid of HIV and AIDS; they are more willing to
be tested for HIV, to disclose their status, and to seek care if necessary.
Finally, people with stigmatizing attitudes also have lower risk perceptions – thus
they are placed at greater risk for infection.
Definitions of Stigma and Discrimination77
Stigma
The holding of derogatory social attitudes or cognitive
beliefs, a powerful and discrediting social label that
radically changes the way individuals view themselves
or the way they are viewed by others
Discrimination
An action based on a pre-existing stigma; a display of
hostile or discriminatory behaviour towards members
of a group, on account of their membership to that group
Assess the client’s risk of infection
A personalised risk assessment is the best way to help clients appreciate their
vulnerability to infection and motivate them to take action. Once clients understand
and acknowledge the behaviours and circumstances that put them at risk of
infection, they can develop a plan to reduce that risk. Effective risk assessments
involve an extended and interactive conversation with the client, following an indepth risk assessment guide (see below).
In-depth HIV/STI Risk Assessment Guide78
1. Do you have a steady sexual partner?
Tell me about your partner.
How long have you been together?
Would you like to talk about what you do with this sexual partner?
Is there anything you are doing to prevent pregnancy or infection with
this partner?
Do you suspect this partner has other sexual partners in addition to
yourself?
Smart, R. (2003). HIV/AIDS-Related Stigma and Discrimination: Training Manual. UNESCO: Paris.
Source: Condom Programming for Prevention of Unwanted Pregnancies and HIV/STI Infections: A
Training Manual for Service Providers. (2006 Draft). UNFPA, WHO & PATH.
77
78
83
Do you feel your partner may have been exposed to HIV or STIs?
Why?
2. Tell me about your other sexual relationships?
How often do you see these other sexual partners?
Would you like to talk about what you do with these sexual partners?
Is there anything you are doing to prevent pregnancy or infection with
these partners?
Do you suspect these persons have other sexual partners in addition
to yourself?
Do you feel these partners might have been exposed to HIV or STIs?
Why?
3. Have you ever been forced to have sex with someone?
What were the circumstances?
Does it still happen?
4. Have you ever had an STI?
Do you have any symptoms now?
Has your partner(or partners) ever had an STI?
Do they have any symptoms now?
5. Have you ever had an HIV test? What was the result?
Has your sexual behaviour changed since you received the results?
6. Do you ever drink alcohol or use other drugs?
Do you ever get together sexually with someone after you are drunk
or high?
7. Have you or your partner(s) ever injected drugs to make you feel good?
When did you or your partner(s) last have an injection?
Have you (or your partners) ever shared a needle with other people,
while injecting drugs?
8. Have you ever had a blood transfusion?
Have you received treatment from a traditional practitioner that
involved cutting or breaking the skin?
9. Have you been circumcised? When and how was this done?
10. Do you think that you are at risk of infection? What behaviours can you
identify that may put you at increased level of risk?
A combination of open-ended and probing questions allows you to discuss the
details and context of the client’s risk factors and help him or her create a personal
risk-reduction plan. Some clients, however, may not feel comfortable to fully
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disclose or discuss their circumstances. In this case, offer clients the guidance they
need to assess their own risks. For example, explain how having multiple sexual
partners’ increases the chance of infection, especially if those partners also have
multiple sexual partners. Then clients can decide if this poses a risk for them
without enumerating their partners.
Assist client to create a risk reduction plan
Based on this discussion, help the client make a personal plan to reduce the risk of
HIV/STI infection. Make sure that the plan is comprehensive, practical, detailed, and
anticipates potential obstacles. For example, the client might decide to:
Talk with a regular partner about using condoms.
Buy condoms and keep them next to the bed.
Carry condoms at all times, even when not planning to have sex.
Use water-based lubricants – in addition to condoms – in particular when
engaging in anal sex.
Avoid alcohol or drink less in order to stay in control.
Carry clean needles and syringes; do not share needles when injecting drugs;
sterilize non-disposable needles; exchange needles at harm reduction sites;
use non-injecting drugs; try becoming ‘clean’ , etc.
Engage in safer sexual practices (e.g. mutual masturbation).
Reduce his/her number of partners and/or be faithful to a single partner.
End a relationship with a partner who is seeing other people.
In addition, you may choose to include discussion of other elements that can reduce
one’s risk, such as not sharing needles; experimenting/engaging in other sexual acts
that have less risk, etc.
Promoting Behaviour Change
Making a plan for changing behaviour is not easy. The provider should ensure that
the stage at which clients are in the behaviour change process is assessed and they
must be assisted accordingly.
85
Stages of Behaviour Change – The Behaviour Change Cycle
Aware of
problem
Motivated
Sustain
to change
change
Skills to
change & act
Evaluate
change
Try new
behaviour
Step 1: Seek to establish where the client is
It is important to try and establish where someone is on the behaviour change cycle
in order to promote behaviour change. Many clients are not even at the beginning of
this cycle – that is, they are not even aware of the problems arising out of their
behaviour.
It may be necessary to first discuss issues with them that will create risk awareness.
Step 2: Encourage movement from knowledge to motivation
Awareness of a problem may still be at the level of heard knowledge. That
awareness needs to shift to a desire to take steps to reduce or overcome the
problem. The provider must check the following:
Does the client want to do anything to change?
What motivation does the client have for (not) changing his/her behaviour?
What could the service provider do/say to help the client to become
motivated to change his/her behaviour?
Does he/she know what steps can be taken to reduce the risk?
Does he/she feel able to take those steps?
This may well involve negotiating some change with the sexual partner. Does
the client have the skills to do this?
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Step 3: Gain skills for the new behaviour
Ensure that skills necessary to implement the new behaviour are readily available to
clients. Help clients practice skills (such as through condom demonstrations for
example or condom negotiation practice) in a safe environment.
Step 4: Provide support for trying new behaviour
Until the client is both aware of the problem and motivated to address that problem,
there is little value in telling them what to do to change their behaviour. Once they
are motivated to change, you can find out what knowledge they have about how to
reduce the problem. You can then provide any additional relevant information and
help them explore which of those behaviour changes they feel they would be able to
implement. Remember that scolding people does not usually encourage positive
behaviour change.
Step 5: Help evaluate the benefits of a new behaviour
The client may have introduced condoms into a relationship.
Do both partners feel satisfied with the condom use? Are there any problems
that they experience?
If so, does the client have any suggestions for resolving those problems?
Remember that the benefits of a new sexual behaviour may not be easy to assess,
and are measured more in the avoidance of health problems.
Step 6: Encourage sustained behaviour change
Remember that behaviour change is not easy, especially when it involves sexual
behaviour where another person is part of that behaviour. Sustained behaviour
change is even more difficult to achieve.
In summary:
Clients need Knowledge about:
o what puts them at risk of STIs, including HIV, and unintended
pregnancies
o what the options are for reducing that risk
Clients need the Attitude of wanting to change their behaviour
Clients need the Skills to:
o change behaviour
o improve communication to negotiate risk reduction with existing (and
future) partners
In encouraging behaviour change in clients, assess whether you need to be aiming at
the head (knowledge), the heart (attitude) or the hands - or genitals! - (skills)
Clients’ HIV self screening
In-depth risk assessments are not possible at many condom outlets, for example, at
kiosks and gas stations. It is possible for clients to screen themselves instead, using
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a brief checklist (see box below). While this approach cannot substitute for an indepth, personalised risk assessment, it may raise clients’ awareness of HIV and STI
risks and prompt them to seek counselling.
HIV and STI self-screening checklist for clients
First, think about yourself:
o Have you ever had sexual relations without a condom?
o Do you have more than one sexual partner?
o Have you ever offered or received money for sex?
o Have ever had an STI?
o Have you ever injected drugs; had a blood transfusion/ treatment
that involved ‘cutting’ or ‘breaking the skin’
Now think about your partner(s):
o Have they ever had sexual relations without a condom?
o Do they have more than one sexual partner?
o Have they ever offered or received money for sex?
o Have they ever had an STI?
o Same as above
If the answer to any of these questions is ‘Yes’, you may be at risk of
infection with HIV or another STI. Talk to a healthcare provider.
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Chapter X: Addressing Myths, Misperceptions and Fears
around Condoms and Condom Use
Objectives
To identify and address common myths, misconceptions and fears regarding
condoms and condom use
To strengthen the knowledge and skills of participants to addressing
common myths, misconceptions and fears
Key Points
Clarifying Myths and Misconceptions while Calming Fears79
Evidence suggests that some service providers may:
Lack sufficient factual information.
Hold religious or cultural beliefs counter to condom use.
Be uncomfortable and embarrassed when communicating about sexuality,
condoms and related subjects.
Be judgmental towards young people, especially young women, wanting to
use condoms.
Support political and/or religious ideology over scientifically sound health
research findings.
Be inexperienced regarding condom use, never having used condoms
themselves and therefore also be unskilled at demonstrating condom
application.
Regard condoms as an inferior form of contraception and suggest other
contraception methods, not recognizing HIV/STIs prevention as a priority.
Service providers and health promoters need to discuss a variety of safer sex
options openly. They must be able to talk about sexuality, male and female sexual
pleasure, local sexual practices and taboos without embarrassment, shame or
judgment. They must be able to help men and women, including adolescents, feel
relaxed and comfortable enough to rethink their sexual relationships and behaviour.
Difficulties arise when health personnel have inadequate and/or inaccurate
information and/or share their clients’ disbeliefs, myths, and negative perceptions
about condoms, and/or when they support an ideological position that is counter to
79
Source: Myths, Misperceptions and Fears Addressing Condom Use Barriers. (2007). IPPF & UNFPA.
89
evidence-based facts. When this occurs, service providers and health promoters
become part of the problem and a barrier to condom use and the prevention of
unintended pregnancy and the transmission of STIs.
Health personnel need appropriate capacity development through access to
accurate information and guidelines to improve their knowledge and
communication skills. They need to have a positive attitude and be able to
communicate clearly, avoiding bias and judgment, without imposing their own
religious and cultural beliefs on others.
With training, effective providers and promoters can be drawn from existing health
personnel, teachers, workplace educators, bar and hotel workers, military
personnel, and peer educators in many different settings.
Overview
Crucial guidelines for health promoters and service providers80
80
Present condoms as an effective technology to prevent unintended
pregnancy and sexual transmission of HIV and other STIs as part of a wider
HIV/STI prevention strategy that also includes promoting: delaying first
sexual experience, abstinence from penetrative sex, and mutual fidelity
between sexual partners.
Challenge gender norms that reinforce inequalities, particularly regarding
condom use, and seek ways to empower women to have a stronger voice in
their own reproductive health.
Debunk myths, correct misperceptions, and calm fears. This requires service
providers to:
o Explore their own beliefs, bias and knowledge.
o Understand the people you are working with and their varied cultural
beliefs.
o Help people gain new insights and knowledge.
o Convey the effectiveness of condoms for the prevention of infection
and unintended pregnancy.
Adopt acceptable language to discuss sexuality and condom use effectively
with potential users. Create open attitudes about condoms and other sexual
issues to help people communicate effectively with their partners.
Respect people’s level of awareness and help them balance their biases with
the benefits of condom use, so that people accept condom use as a
widespread social norm, practiced by influential peers and role models. Be
aware of socio-cultural influences, and engage community, religious, and
political leaders in creating a supportive environment for condom
promotion.
Source: Myths, Misperceptions and Fears Addressing Condom Use Barriers. (2007). IPPF & UNFPA.
90
Service providers should not be judgemental or hold biases towards
condoms or condom use.
Use teaching/learning tools, such as demonstration models, that are as close
to reality as possible.
Approaches to Address Myths, Misperceptions and Fears81
81
Initiate your own local socio-cultural research, such as focus group
discussions (FGD) and key-informant interviews. These FGD should highlight
local myths and belief systems and promote a participatory approach to
sharing and promoting the use of accurate information. Involve trusted
traditional sources of knowledge, such as tribal, community, and religious
leaders, who have a strong influence over the local population.
Provide evidence-based information in multiple ways (print and electronic
media, peer and community key influencers, school classrooms, use of
various languages including street talk, etc.) to ensure that the correct
message is heard.
Offer individual and couple counselling, to address relevant issues and to
enhance your own understanding of the psychology and circumstances of
potential users.
Open a community dialogue and interact regularly with individuals and
couples.
Prepare simple fact sheets and/or flyers to address specific local issues.
Potential condom users should be surveyed when developing material, to
ensure that the information addresses locally relevant needs.
Provide factual information and utilize widely available media such as TV,
radio, community theatre, town crier, discussion groups, health message
boards, etc., that the target audience trusts, believes and widely accesses.
Positive imagery should be used at all times. Persons identified by the
audience as being respected, trusted, admired, believed, or followed (key
influencers) should be included whenever possible in messaging efforts.
Commercial sector techniques provide important tools in meeting social
objectives including stimulating a culture of condom use. “Social Marketing”
is the term used to describe these practical and effective practices. These
practices include market research, testing the effectiveness of all material
and activity, public relations, product promotion, positive imaging, and
increasing the accessibility and the affordability of condoms. These activities
must be maintained over time to effectively modify long term behaviours.
Source: Myths, Misperceptions and Fears Addressing Condom Use Barriers. (2007). IPPF & UNFPA.
91
Common myths and misperceptions82
Condom Quality Assurance
Myths, misperceptions and fears
Condoms have holes that allow the virus to pass through.
Condoms are not reliable and leak.
Condoms break or slip off easily.
Facts
Condoms are made of latex, polyurethane, synthetic material, or animal
tissue and new male and female condoms are being developed by Research
and Development teams around the world. Condom effectiveness also
depends on user behaviour in storing the condom, opening the package,
putting on the condom, sexual activity, removal of the condom, lubrication,
and number of times an individual condom is used.
Latex condoms are the most commonly available and they are frequently
procured by governments, bulk procurement agencies and donors due to
stringent quality assurance procedures and low cost.
The less common animal tissue condom is not suited for HIV/STI prevention
because it is permeable to small viruses such as Hepatitis B and possibly HIV.
Although effective, polyurethane and other synthetic condoms are relatively
more expensive than latex condoms and therefore not routinely purchased
by bulk procurement agencies. They are available through the private sector
and are an alternative to the male latex condom. The polyurethane and
synthetic latex female condoms offer important alternative barrier methods
particularly suitable for women and potentially offering psychological and
empowerment benefits along with protection from HIV/STI.
The Female Health Company’s polyurethane Female Condom is comparable
in effectiveness to other contraceptive methods. The Female Condom (FC) is
highly recommended in situations where the woman is unable to have her
partner use the male condom (MC) and she can more effectively negotiate FC
use. It should also be recommended when one of the intended sexual
partners has allergies to latex and they have access to polyurethane or
synthetic nitrile polymer Female Condoms. There are also male condoms
made of polyurethane that are available for those who are allergic to latex.
Quality assured condoms (male and female) are the most effective available
technology to reduce the sexual transmission of HIV and other STIs. Only
condoms that meet all of the specifications established by WHO or other
qualified authority are packaged for distribution.
Condoms are effective against most STIs, including gonorrhoea and HIV.
They are protective as long as they prevent bodily fluids of one partner
touching the genitals or any mucous membrane of the other person.
Condoms do not protect against infections, such as genital ulcers, which often
82
Source: Myths, Misperceptions and Fears Addressing Condom Use Barriers. (2007). IPPF & UNFPA.
92
occur in areas not covered by the condom. Sexual activity should be avoided
with individuals having open lesions around their genitals until the
individuals have been treated and the lesions have healed.
Condoms stay firmly in place on a erect penis when applied according to
instructions included in its packaging. Condom breakage rate increases with
incorrect use, insufficient lubrication or with the use of non water-based
lubricants.
Consistent and correct use of condoms remains the most effective means of
HIV prevention for people who have sexual intercourse.
Approaches to stimulate confidence in condoms
Be convinced and convincing about the effectiveness of male and female
condoms to prevent unintended pregnancy and HIV/STIs.
Provide factual information in a positive, proactive way without waiting to be
asked. Include information on national and international standards for
quality assurance of condoms.
Demonstrate that condoms do not leak, by filling them with water. Also blow
condoms up like balloons, tie them tightly shut, and put them under water to
see if any air bubbles come out. Whenever possible have potential users do
these experiments themselves.
Provide an illustrative leaflet, or Fact Sheet, demonstrating how to put on a
male or female condom, clearly explaining appropriate use, removal and safe
disposal.
Advise people not to use animal tissue or novelty condoms for HIV/STI
prevention as they may be permeable to some viruses.
Demonstrate the correct use of condoms by using a lifelike replica, your
fingers, a banana, the end of a broom handle or other representative object
for the penis. For Female Condoms, in the absence of a pelvic model, use your
hand and bend your fingers to create a tunnel with the index finger touching
the thumb to represent the vagina. Insert the Female Condom with the other
hand, showing how the outer ring stays outside the vagina. Both of these
demonstrations will require practice beforehand.
Engage in detailed discussion and counselling with couples or individuals
experiencing repeated condom breakage to identify the cause(s) of breakage
and ways of reducing the problem.
Advise individuals and couples to practice putting on a condom in private
until they can do it easily every time, even in the dark. Provide free condoms
for practicing and instruct them to dispose of the condoms afterwards and
not keep the practice condoms for future use.
Hold condom skill education sessions to familiarize boys and men with
condoms and their proper use. Consider similar classes for women and girls.
All education sessions should include both the male condom and the female
condom.
Emphasize four points for condom effectiveness:
1. Use a quality assured, unexpired condom.
2. Leave a small space at the end.
93
3. Assure that the condom is sufficiently lubricated.
4. Insert female condom or put on male condom prior to any sexual
penetration.
Discuss expiry dates and storage requirements and let clients touch and
experience the feeling of quality assured, fresh condoms.
Show clients the difference between the manufactured date and expiration
date marked on the condom package.
Characteristics of condoms: Size, smell and shape
Condoms come in various sizes, shapes and textures and all are available in
developed countries as well as in many developing countries. Couples should be
encouraged to find their own correct size, type and fit, and discuss with each other
what is comfortable, so that condom use becomes the norm in their sexual
encounters and affords them a safer sexual experience.
Myths, misperceptions and fears
Condoms are too big and slip off, exposing the woman to risks.
Condoms are small, tight, constricting and uncomfortable.
Condoms have an unpleasant smell.
Facts
Size
Male condoms are more likely to slip off if they are too large or if lubricant is
used inside the condom directly on the penis. However, total slippage rates
are very low (range from 0.1 to 2.1 percent).
Younger adolescent males need a narrower condom than mature adult males.
Moderate ethnic differences exist on the average size of an erect adult penis,
and individual men of the same ethnic group also differ in erect penis size.
Standards for the size of condoms vary in length from 150mm to 180mm and
width from 42mm to 56mm. ISO specifies one minimum length, whereas the
WHO procurement specification acknowledges that there is sufficient
evidence to recommend a variety of sizes.
Latex condoms are elastic and can stretch to fit any penis size, though a
narrow condom will feel tighter on a wide penis and will cover less of the
shaft of a longer one. Condoms that are tight around the base can constrict
the penis and contribute to a fuller, firmer erection. Men need to experiment
and identify which size of condom they feel most comfortable with. Condoms
are also produced in different shapes. Men who dislike snug-fitting condoms
may prefer slightly larger ones or condoms with a bulbous or twisted end.
The different styles are available commercially in larger urban markets. A
limited range of styles has been included in international specifications for
bulk procurement by international donor organizations.
The Female Condom is about the same length as the male condom but is
wider for a looser fit, allowing freedom in movement that some say provides
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a more natural feeling. Lubricant is used on the inside and the outside of
female condoms.
Smell/fragrance
WHO specifications require manufacturers to test for odour and re-test
before being distributed. An unpleasant smell on some condoms may be due
to chemical residues in the rubber which will usually disappear a few
seconds after the package is opened. Condoms can be made in a wide variety
of colours, tastes and fragrances.
Shape
Condom design may have an effect on pleasure and comfort. Some condoms
fit loosely over the tip of the penis to facilitate friction during intercourse
stimulating the glans (the most sensitive area of the penis.)
The Female Condom is wider than the male condom to allow more freedom
of motion by the male partner. We need to be careful when we state this, as
most couples especially men, dislike the fact that the FC is wide. I think we
should follow up with the following positive statement: ……However once it is
inserted into the vagina, it conforms to the shape and size of the vagina. It has
been noted that the device itself may be unnoticeable under certain
circumstances by some men.
Approaches to address myths, misperceptions and fears
Discuss with clients the reasons for their concerns about condom sizes,
shapes and issues of slippage. Address their concerns with evidence-based
factual information.
Demonstrate how much condoms can stretch, using water, air, a forearm, or
other object. Service providers and health promoters should practice these
demonstrations prior to having an audience.
Make different sizes and shapes of condoms available. Smaller condoms need
to be presented using imagery and words that attract the target audience.
Snug and tight are generally acceptable terms as is stimulating. Larger
condoms should be presented in such a way not to detract from the other
sizes. Local research is always highly recommended.
In countries where taboos exist on women touching their vagina, providers
need to be able to explain to clients how to retrieve a condom that has
slipped off during intercourse. A condom can always be removed from the
vagina.
Reduce any perceived unpleasant condom odour by opening the condom
package in advance to diffuse the smell. The package should only be opened
for a few minutes prior to intended use to reduce the possibility of damaging
it. Aren’t these two statements contradictory?
Sexual pleasure
Some people cite lack of spontaneity and sensation in sex as a downside of using
condoms. A sexually aware individual should be able to address this issue in a
stimulating way and it is up to the service provider and/or promoter to cover these
95
issues during counselling and orientation sessions, and/or in marketing and
promotion activities.
Myths, misperceptions and fears
Condoms reduce spontaneity.
Condoms cause premature ejaculation, and can reduce sensation and
pleasure.
Condoms cause impotence, penile weakness, and loss of erection.
Condoms cause vaginal dryness.
Facts
Sensation
Most condoms are thin enough to provide nearly normal sensitivity when
applied correctly. One must leave a small space at the tip to collect semen
and allow a bit more of the latex to rest behind the glans, allowing that part
of the penis to be more directly stimulated during sexual intercourse. With
practice most people can learn to apply condoms in such a way to add to, not
detract from, the sexual experience.
Spruyt (1998) found, in a global study comparing latex with polyurethane
condoms, that latex condoms are perceived to fit better and are more
effective while polyurethane condoms are believed to be better for
sensitivity, smell better and have better lubrication.
Pleasure
Sexual stimulation can be enhanced when a man allows their partner to put
the condom on him prior to sexual intercourse. A condom which constricts
the shaft of the penis at its base actually helps create a fuller, more rigid
penis, increasing stimulation.
Vaginal dryness
Condoms can not cause vaginal dryness. If the vagina is dry, lubricated
condoms can alleviate the problem or additional water-based lubricant can
be added to the condom or directly to the vagina. Reasons for vaginal dryness
should be explored with the client along with a referral to a physician, if this
is feasible. Causes could be the use of contraceptive pills, a vaginal infection,
ageing or insufficient arousal.
Men may not want to use lubricated condoms where there is a cultural
preference for dry sex as found in some parts of Africa. This practice puts
women at a higher risk for HIV/STI because of increased risk of creating
lesions on the vaginal wall. Condoms are more likely to tear/break when
used without sufficient lubrication.
Psychological factors
Loss of erection, penile weakness, and impotence are more likely due to
issues other than condom use. As in vaginal dryness, these issues should be
96
discussed with the client along with a referral to a physician, if feasible.
There could be medical, physical, or psychological reasons for the condition.
Approaches to address myths, misperceptions and fears
Promote condom use as part of sexual intimacy. Suggest sexual foreplay, such
as the woman applying the condom to the man to avoid loss of arousal due to
a delay in sexual stimulation.
Weigh benefits of using effective latex condoms with the client over the scent
free and more expensive hypoallergenic polyurethane condoms.
Promote attractively packaged condoms with a variety of designs, textures,
colours, scents and flavours, if available. The experimentation with different
condoms can increase stimulation for both partners and increase overall use
rates.
Carry out focus group discussions and interviews with relevant people to
discuss sexual practices and preferences and address risky practices. For
example, lubrication of the vagina is the natural expression of female sexual
arousal, whereas a dry, abrasive vagina can lead to viral and bacterial
infection, with or without condom use, and it is indicative of less female
arousal.
Health concerns
Several misconceptions circulate from time to time that condoms cause health
problems. In addition to these, there are several myths and misunderstandings
about semen. For example, in some countries, semen is thought to give strength and
therefore should be ejaculated into the woman rather than collected in a condom.
Myths, misperceptions and fears
Condoms cause pain, bleeding, infertility in men, infection,disease, foetal
damage, cancer, sores, back or kidney pain, other health problems, death.
Condoms prevent women receiving the benefits of semen.
Retaining semen in the condom can harm the man if it flows back into the
penis.
Using a condom means wasting semen.
Male condoms can get lost in the woman’s body or burst inside her during
sexual intercourse.
Female condoms will get lost in the vagina.
Facts
Condoms can not cause bleeding, infertility, infection, disease, foetal damage,
cancer, or back pain. However, vigorous sex may contribute to some of these
problems. For instance, excessive rubbing of the penis against a dry vagina
can be painful for the woman and sometimes for the man as well, and lead to
bleeding. Vigorous thrusting or an uncomfortable sexual position may cause
back pain.
Condoms provide protection against many health risks, such as unintended
pregnancy, HIV and most STIs, and infertility arising from untreated STIs.
97
This latter issue is particularly relevant for women, over half of whom don’t
show symptoms from many sexually transmitted infections.
Male and female condoms cannot get lodged inside the uterus, nor do they
have any harmful effects on a foetus if the woman is pregnant. The opening to
the cervix is far too small to allow a condom to pass through. On the contrary,
condoms protect both the foetus and the mother from HIV and many other
STIs.
A vagina is a small closed pouch and male or female condoms cannot get lost
in it.
Allergies to latex
A very small number of men and women are allergic to latex or to chemicals
added to latex and these people should not use latex condoms. Allergies
could cause burning and itching and the development of rashes and sores on
the genitals. This type of allergy is categorized as Type 4 contact dermatitis. If
a person is allergic to latex, they must be counselled to use synthetic
condoms such as polyurethane female condoms or polyurethane male
condoms. An individual may experience a reaction to one manufacturer and
not another and should try various brands to see which works best for them.
Allergies to lubricant or spermicide
Some people are allergic to the lubricant or spermicide on some condoms
and may develop rashes and sores. Nonoxynol-9 (N-9) treated condoms can
cause such an allergic reaction22.
The WHO recommends that condoms with Nonoxynol-9 (N-9) spermicidal
treatment no longer be promoted due to adverse side effects. N-9 does not
provide extra protection against HIV/STI23. N-9 actually increases the risk
of HIV infection when used frequently by women at high risk of infection. N-9
also increases the risk of infection through anal sex.
Semen and sperm
Semen is the fluid that protects and carries the sperm to fertilize an egg
(ovum) in human reproduction. All men inevitably “waste” billions of sperm
and litres of semen during a lifetime. They are wasted in a condom, washed
out of a woman’s vagina, or re-absorbed into the man’s body because he has
not ejaculated. All this is completely normal and does not cause any harm to
the man or the woman. Sperm, transported into women by semen, has the
potential to fertilize the female’s egg (ovum). It does not possess any health
benefit to women.
If, on the other hand, the semen is infected with viruses or bacteria, it does
pose a serious health risk to her. This includes infection with HIV,
gonorrhoea, Chlamydia and trichomonoiasis25. Condom use can also reduce
the risk of syphilis, herpes simplex virus (HSV), human papilloma virus
(HPV) and associated disease, including cervical cancer.
98
Approaches to address myths, misperceptions and fears
Discuss negative perceptions of condom use and explain the health
consequences caused by not using condoms consistently. Provide accurate
information about condoms and condom use.
Clarify the associations and relationships that people perceive of condoms
and condom users, as this may highlight why the think condoms are harmful.
Explore and discuss other causes of the problems and issues surrounding
condoms. For those with an allergic reaction to latex condoms, suggest
switching to a latex condom made by another manufacturer. If this does not
solve the problem, advise them to use polyurethane male or female condoms
or synthetic nitrile polymer female condoms (FC2).
Social and moral issues
Condoms are sometimes thought to be associated with illicit or casual sex. Some
people also believe that providing information to young people on condom use for
prevention of pregnancies and STIs, including HIV, will promote earlier first time
sexual experiences and/or increased sexual activity.
Myths, misperceptions and fears
Sex education and condom availability promote early sexual activity and
promiscuity.
Using condoms means you don’t trust your partner.
Male and female condoms are for use with sex workers and for casual sex;
married and long-term partners don’t need
Facts
The WHO and UNAIDS reviewed scientific articles on sex education
programmes in different countries and found two promising results. The first
was that sex education influenced adolescents to delay sexual activity, and
the second was that when these adolescents finally became sexually active,
they were much more likely to have protected sex.
Condom availability makes sexual activity safer rather than increases sexual
activity. Condom promotion leads to reduced sexual activity because people
become aware of the risks.
In countries with strong youth-friendly sexual and reproductive health
services, including easily accessible condoms, the incidence of teenage
pregnancy, abortion and STIs are consistently much lower than in countries
where these services are not available. Anyone might reasonably surmise
that girls are much safer if they know about sex and have the confidence and
skills to say ‘NO’ to sex, or to insist on condom use protection against
infection.
Being mutually faithful with a long-term partner does not remove the risk of
infection unless both partners have a current negative HIV test and both
refrain from behaviours that would place them at risk of future infection.
People can have HIV infection for many years, 10 or more, before they have
any physical signs or symptoms of AIDS.
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Some partners may not be honest about their sexual relationships with
others, past or present. They might lie in order to avoid upsetting or angering
a partner, and not reveal information about other partners.
In a relationship where one partner is HIV-positive, a healthy sexual life is
possible with consistent and correct condom use.
Women have difficulty insisting on male condom use when the relationship
with their partner, spouse or client is one of subservience or inequality. Until
women are free of fear to demand or negotiate safer sex from their partners
they will continue to be in a vulnerable position.
Approaches to address myths, misperceptions and fears
Abstinence and mutual monogamy of non-infected partners are the only
100% effective ways of avoiding sexually transmitted HIV and other sexually
transmitted infections. Mutual monogamy, non-penetrative sexual practices,
and other safe sexual practices, such as consistent and correct condom use,
are valid options to abstinence. Open a discussion of the possibilities through
condom and health promotion activities.
Provide factual information. Explore the reasons why some of your
constituency cannot believe or accept the evidence on condom effectiveness,
sex education and contraceptive service provision.
Use participatory approaches and open discussions with religious, cultural or
other groups opposed to condom use and life skills (sex) education for young
people. Discuss condom use as a way to protect existing life.
Encourage people to associate condom use with protecting their partner and
themselves. It is a caring, respectful, and responsible practice to use a
condom with someone you love. Discuss ways to improve communication
between sexual partners in order to overcome the difficulties women face in
talking to men about sex and negotiating condom use.
Condom use can be suggested for dual protection (to prevent unintended
pregnancy and the transmission of HIV/STI). Young females as well as older
married women should find it easier to insist on condom use for prevention
of pregnancy, rather than HIV/STI, avoiding the issue of stigma, blame and
distrust, while maintaining protected sex.
Explain to married couples and others in long-term relationships, as well as
individuals, that condom use is one of the ways of preventing HIV and
unintended pregnancies. Encourage HIV testing and mutual monogamy
between tested uninfected partners.
Advise sexually active couples to use condoms consistently and correctly in
Voluntary Counselling and Testing (VCT) settings where the HIV+ status of
one or both may have been disclosed.
Other issues
Promoting condoms has been alleged by some people to be a conspiracy of
developed nations to depopulate developing countries. Condom use has also been
blamed for an increase in HIV incidence.
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Myths, misperceptions and fears
Condoms are part of a racist plan against people in developing countries
having children.
As condom use increases, so does HIV.
Condoms are deliberately infected with HIV.
Facts
No study anywhere has found condoms to contain a virus. No study has
found any motivation to infect condoms deliberately.
HIV does not survive outside of the body. As bodily fluid dries, the virus dies.
Condoms have a fascinating history and date back to the 13th Century B.C.
(3300 plus years ago) in Egypt. Anecdotally, they got their present name
from the Earl of Condom, a physician for King Charles II of England in the late
1600’s (A.D.). Whatever the source of the name, they were used to prevent
unintended pregnancies and possibly diseases like syphilis. Men used to tie
pink ribbons around them to hold them in place and to be more attractive to
women. The important thing is they have been recognized for a long time for
their effectiveness.
Although condoms have been around a long time, they have received more
attention since the emergence of the HIV pandemic, as they are the only
device available proven to prevent the transmission of HIV and other
sexually transmitted infections. Private and public sector researchers and
programme managers have spent a great deal of time and energy improving
both the quality and design of these products.
Today there is compelling evidence that correct and consistent condom use
can significantly reduce unintended pregnancy, the risk of HIV infection and
the transmission of other sexually transmitted infections. Condom
promotion and use is combined with other behaviour change strategies, such
as delayed sexual initiation, fidelity and partner reduction, all of which are
effective components of HIV prevention programmes.
Consistent and correct use of condoms provide a high degree of protection
against the transmission of HIV.
Approaches to address myths, misperceptions and fears
Improve the image of condoms and condom use by providing accurate
evidence-based information. Harmonize messages for public information
campaigns and educational programmes with all key stakeholders including
Social Marketing programmes and private sector marketing communications.
Create a positive image, expand distribution points and make varieties of
condoms easily accessible.
Ensure that condom programming becomes an integral component of all HIV
prevention programmes. Promote the efficacy of condoms for pregnancy and
HIV/STI prevention.
Some religious, traditional, political or other leadership oppose condoms due
to the misperception that condom promotion and sexual health education
encourage promiscuity. Suggest clients consider the scientific facts and
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separate overly conservative views from their own reality and their desire
for a healthy, happy, future for themselves and their children.
Use this same methodology when faced with resistance to use condoms for
dual protection or family planning. Open a dialogue with leaders to share
evidence-based and faith-based ideas for prevention.
The Female Condom
The polyurethane Female Condom (FC) produced by the Female Health Company
was the first female condom available to women through donor supported
programs. These include donor subsidized commercial sales programs. The Female
Condom has been subjected to many of the same myths, misperceptions and fears
held against male condoms, and these may be approached in similar ways.
As female condoms are relatively new, further prejudices and fears may also arise.
These need sensitive exploration with clients and potential user groups.
Comparisons must be weighed with other contraceptive methods to determine
which is best for the individual user under their own set of circumstances.
Myths, misperceptions and fears
The Female Condom makes a lot of noise during sex.
The Female Condom is difficult to use.
The inner ring can cause pain to both the man and the woman.
Facts
The Female Health Company acknowledges this concern and state that their
new and improved female condom (FC2) doesn’t make as much noise during
sex. Like most things new, one has to become accustomed to its ways. Some
people are also noisy during sex but to some various sounds can become part
of the enjoyment of the experience.
The Female Condom requires some practice before one can use it with ease.
Since the female condom is a new method, it is recommended to try inserting
it several times before utilizing it in a sexual situation.
The inner ring of the Female Condom should not cause any discomfort if
inserted properly. If it is bothersome, the inner ring can be removed after
using it to insert the Female Condom and before inserting the penis. Some
people report that the inner ring actually adds sexual pleasure to both the
man and the woman.
Some men and women prefer the female condom over the male condom
because it has more space and feels less restrictive. This is especially so when
the female condom has been put on in advance thereby avoiding the loss of
erection that is often discussed while one stops an intimate moment to put
on a male condom.
The Female Health Company produces two condoms. The FC1 is made of
polyurethane while the newer, potentially less expensive FC2 is made of a
nitrile polymer. They are thin, soft, odourless, and strong. The effectiveness
of Female Condoms approximates that of the male condom. “The
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contraceptive efficacy of the female condom during typical use is not
significantly different from that of the diaphragm, the sponge or the cervical
cap.” Effectiveness depends greatly on the correct and consistent use of
barrier methods.
The Female Condom can be used without interrupting sexual spontaneity
since it can be inserted long before sexual intercourse; it does not need to be
removed immediately after ejaculation; and, it does not depend on the male
erection for application.
Female condoms offer more protective coverage because they cover the
women’s internal and some of the external genitalia.
Some couples find the Female Condom erotic, stating that it enhances female
and male sexual pleasure.
Some men prefer the looseness of the female condom over the snugness of
the male condom.
Water-based or oil-based lubricants can be used with the polyurethane
female condom and with the synthetic, nitrile polymer Female Condom
(FC2).
A study in Thailand showed that STI incidence rates were reduced when
women had an option of using a female condom if their partner refused a
male condom.
Approaches to address myths, misperceptions and fears
Try introducing Female Condoms in groups or individual/couple sessions. As
for all condoms, providers and promoters must maintain a non-judgmental
attitude and use plain, non-technical language. Training and encouragement
are beneficial in stimulating correct and consistent usage.
Encourage women to talk to their partners about the female condom as a
contraceptive method35. Promote the dual protection benefits of condoms.
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Chapter XI: Condom Negotiation Techniques
Objectives
To understand the concept of negotiation and apply it to condoms and
condom use
To present the basic condom negotiation techniques
To improve the condom negotiation skills of users
Key Points
Reducing risk encompasses a variety of strategies used by individuals to reduce risk
of infection of HIV and other STIs, including reducing the number of sexual partners,
delaying the onset of sexual activity, and safer sex, including using condoms.
Negotiating safer sex, including condom use with partners is a skill that can be
taught to clients and that can greatly decrease risk exposure. It is also based on
gender inequality or power imbalances in relationships.
Overview
Reducing risk83
A variety of strategies can be promoted by STI prevention programs and used by
individuals to reduce risk of infection. The major strategies include:
1. Reducing the number of sexual partners
2. Delaying the onset of sexual activity in young people
3. Safer sex, including using condoms
Those STIs that are also transmitted through blood exposure, such as human
immunodeficiency virus (HIV), hepatitis B, and hepatitis C, can also be prevented
through infection prevention precautions and safe injection practices.
While these strategies can be highly effective, they are not always easy to
implement, particularly for women who often have little control over the terms of
sexual relations or the behaviour of their partners. Gender issues, such as power
imbalances in sexual relationships, may interfere with condom use and prevent
IPPF. (2008). Condom Negotiation. Online document, available at:
http://www.ippf.org/en/Resources/Contraception/Condom+negotiation.htm
83
104
women from protecting themselves, even if they are aware that their partner’s
behaviour may be putting them at risk. It is often difficult if not impossible for many
women to negotiate safer sex with their partners. Moreover, because of their social
and economic dependency on men, women frequently have little power to refuse
sex or to insist that condoms be used during intercourse.
Safer sex
Safer sex includes practices that reduce the risk of contracting STIs, including HIV
(the virus that causes acquired immunodeficiency syndrome (AIDS). These practices
reduce contact with the partner’s body fluids, including semen, vaginal fluids, blood,
and other types of discharge from open sores.
Safer sex reduces but does not completely eliminate risk. For example, using a
condom correctly and every time for anal, oral, or vaginal sex greatly reduces but
does not totally eliminate the risk for transmission. For some STIs that produce
lesions outside of the area covered by the condom, such as chancroid or herpes,
exposure can still occur with condom use. Although condoms are highly effective,
breakage and slippage can occur, particularly if the condoms are used incorrectly.
What is the most risky kind of sex?
Unprotected anal and vaginal sex with an infected person carry a high risk of disease
transmission. Anal sex is especially risky because it can result in tiny tears or cuts in
the rectum. Viruses can enter the body more easily through these open sores than
through healthy skin. Unprotected oral sex carries a lower risk but is not risk-free.
The use of drugs or alcohol can increase the risk of getting an STI or HIV because
people under the influence may be less careful about practicing safer sex.
What are some forms of safer sex?
Very low or no risk:
Kissing
Massage
Masturbation
Sexual stimulation using your hand on another person
Oral sex on a man who is wearing a condom
Oral sex on a woman using a sheet of latex or plastic wrap (Oral dam)
Low risk:
Anal and vaginal sex using a latex or polyurethane male or female condom
Aside from abstinence or having sex with only one, uninfected partner, using
condoms is the most effective way of preventing sexual transmission of HIV or other
STIs.
105
Remember, it is necessary to have an HIV test three months after engaging in
risky
sexual behaviours to be sure that you are HIV-negative. In addition, some STIs do
not have symptoms for a long time, so it is impossible to know for sure if you are
infected unless you are tested. It is important to learn about partners’ sexual history
and risk of infection as well. However, getting a partner’s sexual history can be
difficult and unreliable. People may not be honest because of fear or shame.
Sometimes a partner may have an STI or HIV but is unaware of it because he or she
does not have any symptoms.
Negotiating safer sex including condom use
Negotiation is a process in which two or more people with different perspectives or
interests interact in order to arrive at a common goal or course of action. This
usually entails compromise on the part of one or both partners. Because of the
sensitive nature of sexuality, negotiating safer sex can be a difficult process for
partners. Women in particular, due to gender inequalities and lack of power within
sexual relationships, may find it difficult, if not impossible, to negotiate safer sex
with their partners. Partners may equate a request for safer sex with an indication
of unfaithfulness and may react negatively, even violently, or may react by
withdrawing financial support or terminating the relationship.
Providers can help clients to gain skills in negotiating safer sex. These include
broaching the topic with a partner in a nonthreatening manner, seeking support
from other outside parties, practicing assertiveness, and providing arguments that
demonstrate the caring impetus behind the request for safer sex.
During counselling about negotiation, providers must always:
Check with client if negotiation is easy or difficulty.
Check out for expected reaction- violence etc
Use stories and videos (if available) to illustrate negotiation
Offer clients brochures for reading at home with partner
Role play negotiation plan with client
Condom negotiation guide for clients and providers84
Try talking to a friend or someone you trust before talking to your partner.
Prepare in advance what you will say and anticipate your partner’s
objections.
Practice different scenarios and responses to you will feel confident. Roleplaying with a friend can help you develop new ways to deal with your
partner.
Source: IPPF. (2002). Programme Guidance on Counseling for STI/HIV Prevention in Sexual and
Reproductive Health Settings.
84
106
Choose a time and place that will allow you and your partner to talk
comfortably, in private, as long as need, without interruptions or
distractions. You may want to agree on a time and place with your partner
ahead of time. The discussion should not take place just before intercourse.
Say clearly and calmly what you know, feel and would like to do.
Talk to your partner in a loving way, but be assertive. Do not plead, and do
not attach, threaten, or blame your partner.
Give your partner time to think and speak. Listen to him or her with an open
mind. Do not assume you know how he or she feels.
Try to have a positive attitude and reach agreement on each point as you go
along.
If your partner refuses to talk to you or will not agree to use condoms, you
may need to ask for help. Consider asking someone your partner repsects
and trusts, such as a close relative or friend, to talk to him or her in your
absence.
You can also ask your partner to come with you to talk to a provider.
Elements of effective counselling
Try to understand how a person’s situation may increase risk and
vulnerability. Understand that there may be circumstances in a person’s life
that are difficult to change (for example, alcohol use, sex work for survival)
and that may make safer sex difficult.
Provide information. Give clients clear and accurate information on risky
behaviours, the dangers of STI, and specific ways to protect themselves.
Identify barriers. What keeps someone from changing behaviour? Is it
personal views, lack of information, or social restraints such as the need to
please a partner? Which of these can be changed and how?
Help people find the motivation to reduce their risk. People often change
behaviour as a result of personal experience. Meeting someone who has
HIV/AIDS, hearing about a family member or friend who is infertile due to an
STI/RTI, or learning that a partner has an infection are all experiences that
can motivate someone to change behaviour.
Establish goals for risk reduction. Set up short- and long-term goals that the
clients think are realistic.
Offer real skills. Teach negotiation skills, demonstrate how to use condoms,
and conduct role-playing conversations.
Offer choices. People need to feel that they have choices and can make their
own decisions. Discuss substitute behaviours that are less risky.
Plan for setbacks. Rehearse how to deal with a difficult situation (for
example, the husband becomes angry or refuses to use condoms).
Special considerations for counselling young people
Counselling young people may take more time.
107
Young people must feel confident that their privacy and confidentiality will
be respected.
Try to establish whether the young person has someone to discuss her/his
problems with.
Be sensitive to the possibility of sexual violence or coercion. Sex with much
older partners may be more likely to be coerced and may carry a higher risk
of HIV or STI.
Make sure the young person understands normal sexual development, and
how pregnancy occurs.
Make sure the young person understands that it is possible to say "no" to sex.
Discuss issues related to drug and/or alcohol use and sexual risk-taking.
It may be useful to involve peers in education.
Check that the adolescent can afford any medicines necessary to treat an RTI
and will be able to take the full course of treatment. Young people are
particularly likely to stop or interrupt treatment if they experience
unexpected side-effects.
Ensure follow-up is offered at convenient times.
Recommendations for Partners to Talk to their Partners
Below is a list of strategies for partners to talk to each other about condom use.
Some of these strategies are more appropriate for unmarried or uncommitted men
and women, who may have more freedom to leave a relationship. With married or
committed couples, joint counselling or individual counselling for the objecting
partner may help.85
Talk about condoms before you are physically close, while you can still
control your feelings.
Practice what you want to say. You can rehearse with a close friend to get
used to saying the words.
Talk about a poster or a radio or television program you have seen or heard
about condoms, or talk about your friends' concerns about condoms.
Say something simple and clear, such as "Let's use this condom for
protection." (Show the condom.)
Be assertive. It is your life and health that you are discussing. Say what you
want very clearly so that there is no misunderstanding. Do not get drawn
into an argument.
Do not drink or use drugs before or when you have sex. If you do, you will
have less control over your actions.
Think and talk about how condoms can be used to increase pleasure and
overall erotic experience of a sexual intercourse. For example, one partner
may put on the male condom with his/her mouth, the female condom may be
fully inserted into the vagina by an erect penis or the partner’s fingers.
Source: IPPF. (2002). Programme Guidance on Counseling for STI/HIV Prevention in Sexual and
Reproductive Health Settings.
85
108
Examples of condom negotiation86
Here are some lines you could use to persuade a partner to use a condom:
She says, "I'm on the pill, don't worry." You say, "I trust you. But I want to protect
both of us just in case."
He says, "We already did it without a condom once." You say, "And that was a
mistake. I worried about being pregnant all month!"
She says, "What — a condom? Are you trying to say that I've cheated on you?" You
say, "I trust you. I use condoms because I care about you, and me, and our future
together."
He says, "I always pull out in time, don't worry."
You say, "I know, but when we use
a condom you don't have to pull out. It can feel even better."
She says, "I can't feel anything when you wear a condom." You say, "That's awful!
Let's wait then and try another brand or size that fits me better and some special
‘warming' lubricant tomorrow."
He says, "I can't keep a hard on with a condom." You say, "I can't relax and enjoy
sex without a condom. So I'll help you stay hard."
You may also want to share with them your safer-sex concerns and some data to
back up your concerns
Every hour of every day around the world, two young people are infected
with HIV.
Young people get sexually transmitted infections (STIs). One out of every
four sexually active adolescents gets infected with an STI each year.
You cannot see or smell most STI infections. That means you can't just look at
a partner and know whether or not he or she is already infected.
Withdrawal is not effective at preventing pregnancy. About 27% of women
become pregnant in the first year when their partners "pull out."
Having a child costs a lot of money.
Presentation slides
EngenderHealth. (2008). STI/RTI Online Minicourse. Online document, available at:
http://www.engenderhealth.org/res/onc/sti/index.html
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Chapter XII: Other HIV Prevention Strategies and
Interventions
Objectives
To review proven HIV prevention strategies
To discuss HIV prevention in the era of expanded treatment access
To present real-world evidence of effectiveness
To explain microbicides, Vaccines, Post Exposure Prophylaxis (PEP) and Pre
Exposure Prophylaxis (PrEP)
Key Points
There is no single solution—no “magic bullet”—to prevent HIV. The most
effective prevention programs are those that use a combination of strategies
to achieve maximum impact.
Overview
Proven HIV prevention strategies87
Over the past two decades, scientific research has identified a range of effective
strategies for preventing all routes of HIV transmission—sexual, blood borne, and
mother-to-child. However, fewer than one in five people at high risk for HIV
currently have access to effective prevention.88 According to an analysis by UNAIDS
and the World Health Organization, expanded access to proven prevention
strategies could avert half of the 62 million new HIV infections projected to occur
between 2005 and 2015.89 Another analysis found that in sub-Saharan Africa alone,
expanded prevention could avert 55% of the 53 million new infections projected to
occur in the region between 2003 and 2020.90 There is no single solution—no
Source: Global HIV Prevention Working Group. (2006). Proven HIV Prevention Strategies. Online
document, available at: http://www.globalhivprevention.org/pdfs/PWG_Proven.pdf
88 USAIDS et al., Coverage of Selected Services for HIV/AIDS Prevention, Care, and Support in Low- and
Middle-Income Countries in 2003, 2004. See also Global HIV Prevention Working Group, HIV
Prevention: The Access and Funding Gap, 2006.
89 J. Stover et al., The global impact of scaling up HIV /AIDS prevention programs in low-and middleincome countries, Science; published online February 2, 2006
90 J. Salomon et al., Integrating HIV prevention and treatment: from slogans to impact, PLoS Med
2005;2:e16.
87
110
“magic bullet”—to prevent HIV. The most effective prevention programs are those
that use a combination of strategies to achieve maximum impact.91
Following are descriptions of the major strategies that, when used in combination,
are effective for preventing sexual, blood borne, and mother-to-child HIV
transmission.
Preventing sexual transmission: What works
Globally, sexual transmission is responsible for the majority of new HIV infections.
Behaviour change programs
Behaviour change programs seek to encourage people to adopt safer sexual
behaviours that can reduce the risk of acquiring and transmitting HIV. They include:
Remaining sexually abstinent or delaying initiation of sexual activity
Decreasing the number of sexual partners
Using condoms consistently and correctly if sexually active
A number of studies have documented the effectiveness of behaviour change
programs among a broad range of populations at risk of HIV infection, including:
Sex workers92
Men who have sex with men93
School-age youth94
Research indicates that the most effective behaviour change programs are tailored
to the needs and values of the groups they are designed to reach. For example,
Thailand was able to reduce new HIV infections from 143,000 in 1991 to 19,000 in
2003 through behaviour change programs targeted to high-risk groups, including
widespread condom distribution to sex workers and their clients at the country’s
brothels.95
Encouraging abstinence has an important place in HIV prevention, especially among
young people. Research indicates that providing people with comprehensive
See J. Auerbach & T. Coates, HIV prevention research: accomplishments and challenges for the third
decade of AIDS, Am J Public Health 2000;90:1029-32.
92 See UNAIDS, Female Sex Worker HIV Prevention Projects: Lessons Learnt From Papua New Guinea,
India, and Bangladesh, 2000.
93 For example, R. Valdiserri et al., AIDS prevention in homosexual and bisexual men: results of a
randomized trial evaluating two risk-reduction interventions, AIDS 1989;3:21-6.
94 For example, J. Jemmott et al., Reductions in HIV risk-associated sexual behaviours among black male
adolescents: effects of an AIDS prevention intervention, Am J Public Health 1992;82:372-7.
95 UNDP, Thailand’s Response to HIV/AIDS: Progress and Challenges, 2004.
91
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information on reducing HIV risk—including abstinence, partner reduction, and
correct condom use—is most effective at preventing new infections.96, 97, 98
Condoms
Condoms are highly effective at preventing sexual transmission of HIV. A 2001
report by the U.S. National Institutes of Health analyzed several studies on condom
effectiveness, and concluded that consistent use of condoms can reduce an
individual’s risk of HIV transmission by 85%.99 Condoms are also effective at
preventing other sexually transmitted diseases, such as gonorrhea.
HIV Testing
Encouraging testing for HIV is critical for prevention, yet fewer than 1% of adults in
developing countries had access to HIV testing in 2005.100 Studies have shown that
people who know their HIV status are more likely to protect themselves and others
from infection. For example, a study in Kenya, Tanzania, and Trinidad found that
when men and women learned whether they or a partner was HIV -infected, they
were significantly more likely to practice safer sex.101
Prompt diagnosis and treatment of other STIs
Infection with other sexually transmitted infections such as gonorrhea increases
the risk of HIV acquisition and transmission by at least two to five times,102 and
studies have found that promptly detecting and treating STIs can help reduce HIV
risk. For example, a study in Tanzania found that treating STDs reduced the rate of
new HIV infections by 38%.103
Other studies have suggested that STI control efforts are most effective at
preventing HIV when they are initiated as early as possible in the course of a
country’s epidemic and are targeted toward people at highest risk.104
See J. Jemmott et al., Abstinence and safer sex HIV risk-reduction interventions for AfricanAmerican adolescents: a randomized controlled trial, jama1998;279:1529-36.
97 See J. Shelton et al., Partner reduction is crucial for balanced “abc” approach to HIV prevention,
British Medical Journal, 2004;328:891-3.
98 See U.S.Office of the Surgeon General, The Surgeon General’s Call to Action to Promote Sexual
Health and Responsible Sexual Behaviour, 2001.
99 U.S. National Institute of Allergy and Infectious Diseases, Scientific Evidence on Condom
Effectiveness for Sexually Transmitted Disease Prevention, 2001.
100 UNAIDS, Report on the Global AIDS Epidemic, 2006.
101 Voluntary HIV-1 Counseling and Testing Efficacy Study Group, Efficacy of voluntary HIV-1
counseling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial,
Lancet 2000;356:103-12.
102 For a review of studies on STDs and HIV risk, see Institute of Medicine, The Hidden Epidemic:
Confronting Sexually Transmitted Diseases, 1997.
103 H. Grosskurth et al., Impact of improved treatment of sexually transmitted diseases on HIV infection
in rural Tanzania: randomized controlled trial, Lancet 1995;346:530-6.
104 G. Garnett et al., Strategies for limiting the spread of HIV in developing countries: conclusions based
on studies of the transmission dynamics of the virus, J Acquir Immune Defic Syndr Hum Retrovirol
1995;9:500-13.
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112
Preventing blood borne transmission: What works
Injection drug use accounts for an estimated 10% of HIV infections globally, and
transfusion of HIV-infected blood is believed to be responsible for an additional 5%
to 10% of infections. Sub-standard hygienic practices in some health care settings
also pose a risk of HIV transmission.
Harm reduction programs for Injection Drug Users
Harm reduction programs that provide clean needles and syringes have been shown
to be effective in reducing the risk of HIV acquisition and transmission among
injection drug users, without contributing to an increase in drug use. For example:
An international analysis of 81 cities found that the number of people
infected with HIV decreased an average of 6% in cities with needle and
syringe programs, while HIV rates increased 6% in cities without these
programs.105, 106
A review of more than 400 scientific papers and public health reports found
no evidence that needle and syringe programs are associated with an
increase in the number of people injecting drugs.107
Needle and syringe programs also connect drug users to other health
programs. A 2002 report by the U.S. National Institute on Drug Abuse
concluded that these programs “serve as a bridge...by offering opportunities
for HIV testing, and by providing referrals for drug abuse treatment.”108
Blood supply safety
In developed countries, routine screening of the blood supply has virtually
eliminated the risk of HIV transmission through donated blood.109 In recent years, a
number of developing countries have also put in place procedures and technology to
protect the blood supply. For example, India has made blood safety a significant
focus of its HIV control efforts.
UNAIDS recommends three essential elements of an effective blood safety program:
1. National blood transfusion service run on a not-for-profit basis
2. Policy of excluding paid donors and relying on voluntary, low-risk donors
3. Screening all donated blood for HIV110
S. Hurley et al., Effectiveness of needle exchange programs for prevention of HIV infection, Lancet
1997;349:1797-800.
106 See also A. Wodak & A. Cooney, Do needle syringe programs reduce HIV infection among injecting
drug users? A comprehensive review of the international evidence, Sub Use & Misuse2006;41:777813.
107 Monitoring the AIDS Pandemic Network, Drug Injection and HIV /AIDS in Asia, 2005.
108 U.S. National Institute on Drug Abuse, Principles of HIV Prevention in Drug-Using Populations: A
Research-Based Guide, 2002.
109 19 E. Sloand et al., Safety of the blood supply, JAMA, 1995;274:1368-73.
110 UNAIDS, Blood Safety and HIV, 1997.
105
113
Infection control in health care settings
Countries that require health workers to adopt “universal precautions” have
succeeded in making HIV transmission extremely rare in health care settings.111
This approach treats every patient as potentially infectious, requires workers to
wear protective gear, and trains workers to use syringes properly and sterilize all
equipment and surfaces.
Supportive policies
HIV prevention is most effective when it is supported by strong and visible political
leadership, and by policies that address the root causes of vulnerability to HIV,
including:
Anti-stigma measuresthat prevent discrimination against people with HIV
and vulnerable groups
Gender equality initiatives,including programs to enhance women’s
education and economic independence, and laws to combat sexual violence
and trafficking
Involvement of communities and HIV -infected individuals in educating
people about HIV, and in developing, implementing, and evaluating
prevention programs
HIV prevention in the era of expanded treatment access
Access to antiretroviral treatment is at last becoming a global priority. Yet long-term
success against HIV requires simultaneous expansion of both treatment and
prevention. Unless the incidence of HIV is sharply reduced, treatment will not be
able to keep pace with all those who need it.
For example, while more than 1 million people are currently receiving antiretroviral
treatment, more than 4 million new HIV infections occur every year.112
New opportunities
HIV treatment provides new opportunities to revitalize prevention. As access to
antiretrovirals expands, millions of people could be drawn into health care settings,
where HIV prevention counseling, condoms, and other services can be delivered.
In addition, there is evidence that the increased availability of treatment leads to
increased HIV testing rates.113
E. Wong et al., Are universal precautions effective in reducing the number of occupational
exposures among health care workers? jama1991;265:1123-8.
112 WHO, Progress on Global Access to HIV Antiretroviral Therapy: An Update on “3 by 5,” 2006. See
also UNAIDS , Global Report, 2006.
113 Ibid.
111
114
As more people know their HIV status, prevention strategies can target the different
needs of people who are HIV -infected and those who are not.114
New challenges
Access to treatment also presents new challenges for prevention. Experience in
industrialized countries suggests that HIV treatment access—if not accompanied by
prevention—can alter people’s perception of the risk of HIV, and lead to increases in
risk behaviour and new infections.115
Research highlights the importance of pairing treatment and prevention. In Uganda,
when HIV -infected adults were provided antiretrovirals along with prevention
counseling, condoms, and HIV testing for their partners, risky sexual behaviour
declined by 70%, and there were few instances of HIV transmission to uninfected
partners.116 In India, projections by the World Bank estimate a savings of millions of
lives if condom use remains stable or increases in the era of expanded treatment
access. However, if condom use decreases by just 10%, HIV rates could actually
increase, underscoring the critical need for HIV prevention and treatment to be
brought to scale simultaneously.117
Preventing mother-to-child transmission: What works
In 2005, 700,000 children under age 15 were infected with HIV, the vast majority
from their mothers—in the womb, during birth, or through breastfeeding. The best
strategy for preventing mothers from transmitting HIV to their newborns is to help
women of childbearing age avoid HIV infection in the first place. However, for
women who are infected, there are a number of effective strategies for preventing
mother-to-child transmission:
Antiretroviral Drugs
A landmark clinical trial in 1999 and subsequent studies have shown that the
inexpensive antiretroviral drug Nevirapine can reduce the risk of an HIV -infected
mother transmitting HIV to her child by nearly 50%.118, 119 One dose of Nevirapine
is given to the mother at the onset of labor, and one dose is given to the newborn
within 72 hours of birth.
See CDC, Incorporating HIV prevention into the medical care of persons living with HIV, MMWR
2003;52:1-24.
115 25 R. Valdiserri, Mapping the roots of HIV /AIDS complacency: implications for program and policy
development, AIDS Ed & Prev 2004;16:426-39.
116 R. Bunnell et al., Changes in sexual behaviour and risk of HIV transmission after antiretroviral
therapy and prevention interventions in rural Uganda, AIDS 2006;20:85-92.
117 M. Over et al., HIV /AIDS Treatment and Prevention in India: Modeling the Costs and
Consequences, World Bank, 2004.
118 28 L. Guay et al., Intrapartum and neonatal single-dose nevirapine compared with zidovudine for
prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIV net012randomized trial,
Lancet 1999;354:795-802.
119 See also Institute of Medicine, Review of the HIV net012Perinatal HIV Prevention Study, 2005.
114
115
Combinations of antiretrovirals—including Nevirapine, Zidovudine (azt) and/or
3tc—are also used to prevent mother-to-child transmission, and can reduce the risk
of infection even more than Nevirapine alone. However, single-dose nevirapine is
often more affordable and practical for resource-limited settings.120
Breastfeeding alternatives
The chance of an HIV-infected mother transmitting HIV to her newborn increases by
up to half with prolonged breastfeeding. Ideally, HIV-infected mothers should have
access to breast-feeding alternatives, such as infant formula. Early weaning from
breastfeeding may also help minimize HIV transmission.121
Caesarean delivery
Caesarean delivery also significantly reduces the risk of mother-to-child HIV
transmission.122 However, caesarean deliveries are often not available or practical
in developing countries, where many women lack access to hospital birthing
facilities.
Microbicides123
A microbicide is a compound whose purpose is to reduce the infectivity of viruses or
bacteria.
The term has come to refer to a potential product which would prevent the
transmission of HIV and other sexually transmitted infections (STIs) inside a
woman’s vagina. A rectal microbicide would act similarly to protect men who have
sex with men and women during anal intercourse.
There are different candidate
microbicide products currently under research and development; many are in the
form of a gel or cream to be applied to the surface of the vagina.
Scientists are also exploring other ways of drug delivery such as by a vaginal ring
which would be inserted into the vagina and provide controlled release of an
effective microbicide. Mechanisms of action
A successful topical microbicide – applied to the vagina surface - would probably act
in a combination of ways. Scientists are researching different products which would:
Kill pathogens without damaging the healthy cells of the vagina
WHO, Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants,
2004.
121 A. Coutsoudis et al., Influence of infant-feeding patterns on early mother-to-child transmission of
HIV -1 in Durban, South Africa: a prospective cohort study, Lancet 1999;354:471-6.
122 International Perinatal HIV Group, The mode of delivery and the risk of vertical transmission of
human immunodeficiency virus type 1: a meta-analysis of 15 prospective cohort studies, New Eng J Med
1999;340:977-87.
123 UNAIDS. Microbicides: Why are they significant? 2008.
120
116
Strengthen the body’s natural defence system by increasing the natural
acidity of vagina inactivating athogenic viruses and bacteria
Inhibit the virus getting into the white blood cells – the target cells of HIV
Inhibit viral replication by using derivatives from anti-retroviral drugs
For some women, it is important that the action of the microbicide not impair their
ability to conceive a baby. Both contraceptive and non-contraceptive microbicides
are currently under development, as well as rectal microbicides for heterosexual
women and men who have sex with men.
No silver bullet
Some advocates believe that the successful development of a microbicide would
bring significant emancipation for women who due to cultural, economic and social
drivers are disempowered and unable to protect themselves from HIV.
With the stakes so high, microbicides seem like a very attractive solution. However
experts are realistic about the complexity of the research task and drug efficacy and
urge caution over raising unrealistic expectations. Successful microbicides
products will be partially protective. Although they may be up to 80% effective in
preventing the transmission of HIV during sexual intercourse, they would need to be
complimented by other prevention tools in a combination prevention strategy.
Vaccines124
Each day nearly 7,000 people worldwide become newly infected with HIV. Current
prevention measures can slow the spread of the virus. But the best hope of ending
the epidemic lies in a vaccine. However, developing a vaccine against HIV presents
enormous challenges. The virus mutates extremely rapidly, enabling it to evade
weapons designed to cripple it.
A large number of scientists in pharmaceutical and biotechnology companies,
academic laboratories and government institutions are engaged in the search for a
vaccine, and are targeting a variety of different stages in the lifecycle of the virus.
However, a breakthrough is not expected imminently.
Protection of animals against AIDS-like disease with a vaccine has been reported,
but it remains uncertain as to whether that success can be extrapolated to humans.
The search for an HIV vaccine therefore has to include laboratory and animal
experiments, as well as human clinical trials which are costly and time-consuming.
HIV is a moving target. The virus is very variable (as is the virus responsible for flu),
and it is not known whether a vaccine protecting against one subtype of HIV would
also protect against the other subtypes.
UNAIDS. (2008). Vaccines. Online document, available at:
http://www.unaids.org/en/PolicyAndPractice/ScienceAndResearch/Vaccines/
124
117
Developing an effective vaccine means more than just getting the science right. It
means ensuring that such a vaccine is affordable to developing countries, and is easy
to transport, store and administer even where the health infrastructure is poor.
Currently, only about 1% of all funds spent on health product development go
towards this vital endeavour.
The Potential Impact of an AIDS Vaccine125
Scientists are working hard to develop a vaccine to prevent HIV. It is likely that the
first generation of successful HIV vaccines will offer some form of protection, but
they will not be entirely protective (as no vaccine is 100% effective). Future
generations of a preventive HIV vaccine will become increasingly more effective
over time as scientific knowledge improves.
Even partially effective vaccines could make a difference by:
protecting some vaccinated individuals against HIV infection;
reducing the probability that a vaccinated individual who later becomes
infected will transmit the infection to others; or
slowing the rate of progression to AIDS for those who later become infected
with HIV.
The International AIDS Vaccine Initiative (IAVI) estimates that – even assuming that
other programs for treatment and prevention have been scaled up – an HIV vaccine
could substantially alter the course of the AIDS pandemic and reduce the number of
people newly infected, even if vaccine efficacy and population coverage levels are
relatively low.
New adult HIV infections in low- and middle-income countries by year and vaccine
scenario (The introduction of a vaccine at 2015 was chosen for illustrative purposes.
A vaccine is not guaranteed by 2015.)
An AIDS Vaccine Could Have an Enormous Effect
The world has committed to providing universal access to AIDS prevention,
treatment and care; but unless we can alter the number of people who become
infected, the costs of treatment and care will mount into the tens of billions of
dollars, even before considering rising drug resistance and the associated need for
more expensive alternative drugs. Moreover, these costs must be met every year for
the foreseeable future.
But some groups could especially benefit from an HIV vaccine, particularly
marginalized and vulnerable populations, including women who often have the least
access to prevention, care, and treatment services. The challenges in reaching these
underserved populations underscore the importance of making investments in HIV
vaccine research and development today.
IAVI. (2008). Why the world need an AIDS Vaccine? Online document, available at:
http://www.iavi.org/viewpage.cfm?aid=7
125
118
The negative effects of the AIDS pandemic are substantial, in terms of lives lost,
human suffering, shattered families and communities, lowered economic
productivity and higher health care costs. A vaccine that could reduce the number of
new infections by 20% to 80% would produce enormous health and economic
benefits and could help to dramatically curtail the pandemic.
119
Post Exposure Prophylaxis (PEP) and Pre Exposure Prophylaxis
(PrEP)126
Post Exposure Prophylaxis (PEP) and Pre Exposure Prophylaxis (PrEP) are special
types of drug treatment that aim to prevent people from becoming infected with
HIV.
What is Post Exposure Prophylaxis (PEP)?
Post Exposure Prophylaxis (PEP) is antiretroviral drug treatment that is started
immediately after someone is exposed to HIV. The aim is to allow a person’s
immune system a chance to provide protection against the virus and to prevent HIV
from becoming established in someone’s body. In order for PEP to have a chance of
working the medication needs to be taken as soon as possible, and definitely within
72 hours of exposure to HIV. Left any longer and it is thought that the effectiveness
of the treatment is severely diminished.
PEP usually consists of a month long course of two or three different types of the
antiretroviral drugs that are also prescribed as treatment for people with HIV. As
with most antiretrovirals these can cause side effects such as diarrhoea, headaches,
nausea/vomiting and fatigue. Some of these side effects can be quite severe and it is
estimated that 1 in 5 people give up PEP treatment before completion.
The most common drugs prescribed for PEP are zidovudine, lamivudine and
nelfinavir. For more information about these drugs, have a look at our antiretroviral
drugs table.
What is Pre Exposure Prophylaxis (PrEP)?
Pre-exposure prophylaxis (PrEP) refers to a form of treatment that can be taken
before exposure to a disease in an attempt to prevent infection. In respect of
HIV/AIDS, PrEP consists of antiretroviral drugs to be taken before potential HIV
exposure in order to reduce the risk of HIV infection.
The antiretroviral drugs that are currently being tested for PrEP treatment are
tenofovir and emtricitabine or tenofovir alone. Taken once a day, these drugs have a
low level of side effects and slow development of associated drug resistance1.
Do PEP and PrEP Work? Are PEP and PrEP Effective?
It is not known exactly how effective PEP and PrEP are, as it is extremely difficult to
carry out human trials.
Who would benefit from PEP?
Since the beginning of the 1990s in most areas of North America and Europe, PEP
has been available to health workers as an important aspect of safety in the
workplace. In 2005, clinical guidelines from the United States Department of Health
Source: AVERT. (2008). PEP and PrEP. Online document, available at: http://www.avert.org/pepprep-hiv.htm
126
120
and Human Services were drafted to extend the recommendations on using PEP to
non-occupational circumstances. Nowadays in several different countries anybody
who believes they have been exposed to HIV is able to ask for PEP treatment at
accident and emergency areas in hospital, through GUM or HIV clinics, and via some
medical doctors experienced in treating HIV.
The question of who should receive PEP has proved to be quite controversial.
Several cost-benefit analyses have revealed that providing PEP to all nonoccupational exposures is not an economically efficient use of limited HIV treatment
resources12. PEP appears to be cost-effective only when the patient has engaged in
unprotected receptive anal intercourse or when the patient knows the HIV status of
the partner.
Some believe that the increasing availability of PEP will lead to behavioural changes.
The theory is that if PEP is readily available people will be less likely to use condoms
or will be less cautious, knowing that there is a potential back up13.
It has also been suggested that due to its availability, people may use PEP over and
over again. However, various studies have shown that increasing awareness and
availability of PEP does not lead to increasing risky behaviour. There is also little
evidence showing that people will frequently rely on PEP, probably due to the
adverse side effects that the treatment can involve. In particular a study in the US
showed that “people reduced their risk behaviour after using PEP, rather than
increasing it”14.
Unfortunately there are still some places around the world where PEP is being
denied to people who need it. For example research in South Africa revealed that
many victims of rape were not receiving PEP treatment.
“Rape survivors are not receiving vital anti-HIV treatment due to ignorance and a
lack of basic treatment procedure at government health facilities and justice
departments” - (IRIN, 2007)15.
Some men and young boys in South Africa have also been denied the treatment due
to homophobia and general ignorance regarding male-on-male rape.
Who would be likely to benefit from PrEP?
Different groups of people could potentially benefit from PrEP in the antiretroviral
drug form. A review of PrEP published by the Center for HIV Identification,
Prevention, and Treatment Services, explains that in California PrEP would benefit
men who have sex with men (MSM), female partners of MSM and injection drug
users and their partners16. There have been claims that people are taking tenofovir
before a high-risk night out17. The U.S. Centers for Disease Control and Prevention
recently carried out a survey at four gay-pride events and found out that 7 percent
of the interview sample had tried taking tenofovir18.
121
There are cases of couples wishing to conceive a child where one partner is HIV
positive and the other HIV negative. It has been thought that couples with different
HIV status may be able to conceive without transmitting infection by using the
antiretroviral drug form of PrEP. PrEP could be used as an alternative to sperm
washing, a procedure currently being used in many parts of the developed world by
HIV different couples. Sperm washing is costly and is believed to have a low
conception rate, which is why PrEP could be a more effective option19. For more
information about sperm washing, take a look at our pregnancy page.
It has been suggested the PrEP would be an effective way to “protect women (and
men) who are victims of sexual violence or coercion, or who are afraid to insist that
their partners use condoms”20. Worldwide the most common form of HIV
transmission is through unprotected vaginal sex with an infected partner. Therefore
millions of other people could conceivably benefit from taking a pill a day as a way
of reducing their risk of contracting HIV.
Opt out
Thickening of cervical mucous
122
