Comprehensive Condom Programming- A guide for resource mobilization and country programming
Publication date: 2010
Comprehensive Condom Programming A guide for resource mobilization and country programming 12 Rationale In most parts of the world, HIV is spread primarily through unpro- tected sexual intercourse. Changing behaviour to promote safer sexual practices, including condom use, is therefore fundamental to control- ling the epidemic. Male and female condoms are key because they are currently the only barrier methods that protect against sexually transmitted infec- tions (STIs), including HIV. Correct and consistent condom use is one of the most effective means of preventing sexual transmission of HIV, and it belongs at the heart of any HIV prevention strategy. Moreover, experience has shown that actions to increase uptake and use of effective barrier methods are more successful and sustainable when they are part of a strategic, coordinated and com- prehensive condom programming effort. Despite this knowledge, condom programming has not been scaled up at the urgent pace the epidemic demands. In many countries, condom programming is hampered by weak political leadership and inadequate resources. But this can change. 1 2 Condoms are effective Strong evidence from laboratory and clinical studies shows that condoms effectively reduce the risk of HIV transmission. For specific populations, increased levels of condom use are also associ- ated with decreased rates of reported STIs. Male and female condoms play a central role in halting the rising rates of STIs, including HIV. For people who are not practising monogamous sex with an uninfected partner, condoms remain the best tool for reducing the risk of acquiring STIs (if uninfected) or transmitting these infections (if infected). Condoms are cost-effective There are no published studies on the cost-effectiveness of promoting male condoms as a stand-alone intervention. However, recent national population-based surveys in seven sub-Saharan African countries have shown that an increase in condom use – in conjunction with delayed sexual debut and a reduction in sexual partners – is an important factor in the decline of HIV prevalence, contributing to substantial savings in terms of lives and costs. Introducing female condoms into programmes already promoting male condoms has been shown to increase the number of protected sex acts and to provide an option to women who are less likely to use other dual-protection methods (i.e., methods that protect against both STIs and unintended pregnancy). Female condom programmes are especially likely to be cost-effective in areas of high STI/HIV prevalence, even among women with moderate rates of partner change. Female condoms and male condoms are roughly equivalent in terms of their effectiveness in reducing the risk of HIV transmission. However, female condoms are far more costly. Cost- effectiveness results are therefore sensitive to assumptions made about the rate of substitution between the two types of condoms (that is, the portion of sex acts covered by female condoms that would have been covered by male condoms had the female condoms not been available). In reality, the female condom has its own niche – specifically, among women and girls who are unable to insist that their male partners use condoms. Their partners may be reluctant to use male condoms, even when available, and women often lack the power to negotiate their use. The UNFPA Programme Guided by international development principles, UNFPA pledges to: � ;dikh[�j^Wj�Wbb�YedZec�fhe]hWcc_d]�[\\ehji�Wh[�dWj_edWbbo�emd[Z�WdZ�Yekdjho#b[Z � 7ii_ij�dWj_edWb�>?L#fh[l[dj_ed�fhe]hWcc[i�je�Z[l[bef�YedZec�fhe]hWcc_d]�ijhWj_[i� through which every sexually active person at risk of HIV/STIs – regardless of age, culture, economic situation, gender, marital status, religion or sexual orientation – has access to good quality condoms when and where s/he needs them, is motivated to use male or female condoms as appropriate, and has the information and knowledge to use them consistently and correctly. UNFPA has facilitated the design and implementation of culturally appropriate and effective efforts towards comprehensive condom programming (CCP). For example, in many countries, UNFPA has helped coordinate the security of national reproductive health commodities and develop condom support teams. In some countries, existing bodies or institutions already man- age condom planning and coordination, so additional assistance is not necessary. These working groups include representatives from government, the private sector, civil society and donor agencies working on HIV prevention and reproductive health programmes. In supporting this effort, UNFPA employs a 10-Step Strategic Approach (outlined on the follow- ing pages) to scale up CCP that encourages the participation of donors and international agencies while placing ultimate responsibility for decision-making and implementation in the hands of national partners. This 10-step approach is being implemented in selected countries in most regions. The design of a condom programme may vary from country to country depending on many factors, ranging from the local epidemiology of STIs/HIV and the condition of a country’s health infrastructure to the cultural context of targeted areas and budgetary issues. However, the process of designing and implementing a SMART (specific, measurable, achievable, realistic and time-governed) strategy has many common features, which are described in this document. 3 Assemble a team from an existing reproductive health commodity security working group and/or HIV prevention committee. The team should include representatives from: ��B_d[�c_d_ijh_[i��ikY^�Wi�^[Wbj^"�ÆdWdY["� gender, education and tourism) ��?dij_jkj_edi�meha_d]�_d�\Wc_bo�fbWdd_d]�WdZ�� � sexual and reproductive health � DWj_edWb�7?:I�YekdY_b � BeYWb�YedZec�¾Y^Wcf_edi¿ ��HkbWjeho�Wkj^eh_j_[i�h[ifedi_Xb[�\eh� local standards and quality assurance � :edeh�Yecckd_jo ��9_l_b�ieY_[jo��_dYbkZ_d]�f[efb[�b_l_d]�m_j^� HIV, young people, faith-based and non- governmental organizations) � IeY_Wb�cWha[j_d]�eh]Wd_pWj_edi � Fh_lWj[�i[Yjeh�WdZ�Xki_d[ii�YeWb_j_edi$� The purpose of the team is to provide guidance and support to government in developing and monitoring the national CCP strategy and opera- tional plan. The team should have clearly designated roles and responsibilities. Undertake a desk review of documents, reports and research pertaining to HIV and sexual and reproductive health to gain background information on the various components of the CCP framework (leadership and coordination; demand, access and utilization; supply and commodity security; and support). Where information from the desk review is insufficient, collect data from the field (see the CCP Rapid Needs Assessment and Strategic Planning Tool). Convene a stakeholders meeting to share findings from the situation analysis, build consensus and support, and agree on a concrete roadmap for scaling up condom programming efforts. STEP 2 Undertake a situation analysis The 10-Step Strategic Approach STEP 1 Establish a national condom support team DEVELOPMENT PHASE 4 STEP 2 Undertake a situation analysis Develop a comprehensive and integrated national strategy for male and female condoms STEP 3 Develop a multi-year operational plan and budget STEP 4 Identify responsible agencies and/or stakeholders to implement and oversee coordinated activities in each of the following areas and, if possible, link them programmatically. The national strategy should reflect the components of the CCP framework: B[WZ[hi^_f�WdZ�YeehZ_dWj_ed� ��9eehZ_dWj_ed�e\�fWhjd[hi^_fi ��7ZleYWYo� ��Feb_Y_[i�WdZ�hkbWj_edi� ��H[iekhY[�ceX_b_pWj_ed Demand, access and utilization � CWha[j�h[i[WhY^� � JejWb�cWha[j�WffheWY^ � JWh][j[Z�Z_ijh_Xkj_ed � ?;9�WdZ�X[^Wl_ekh�Y^Wd][�� communication strategies ��IeY_Wb�ceX_b_pWj_ed� Supply and commodity security � <eh[YWij_d]� � FheYkh[c[dj � GkWb_jo�WiikhWdY[ � MWh[^eki_d]�WdZ�ijehW][ � :_ijh_Xkj_ed�je�ikffbo�Y^W_di � Be]_ij_Yi�cWdW][c[dj�_d\ehcWj_ed�ioij[c Support � 7ZleYWYo � IeY_Wb"�X[^Wl_ekhWb�WdZ� operations research � 9WfWY_jo�WdZ�_dij_jkj_edWb�ijh[d]j^[d_d] � Ced_jeh_d]�WdZ�[lWbkWj_ed � :eYkc[djWj_ed�WdZ�Z_ii[c_dWj_ed$ For each component of the national condom strategy, including integration with other programmes and the steps outlined below, ensure that the operational plan specifies: � 7Yj_l_j_[i � :_l_i_ed�e\�bWXekh�\eh�[WY^�fWhjd[h � J_c[�\hWc[ � 9eij � FheY[ii�_dZ_YWjehi$ Most importantly, ensure the buy-in of key ijWa[^ebZ[hi"�_dYbkZ_d]�¾]Wj[#a[[f[hi¿"�Xo� including them in important programme decisions. 5 Identify available, committed and potential resources at the local, national, regional and global levels in the areas of HIV prevention, treatment, care and support, and sexual and reproductive health, to scale up CCP. Determine funding gaps in the operational plan. Advocate and secure funds for implementa- tion of the operational plan. Develop a reporting system to provide routine feedback about programme implementation to donors. STEP 6 Mobilize financial resources Based on the operational plan: Link the multi-year operational plan with the national commodity security plan STEP 5 B_da�j^[�ef[hWj_edWb�fbWd"�m^[h[�feii_Xb["� to the existing logistics system for essential drugs and reproductive health and HIV- related commodities, including systems for forecasting, procurement, distribution and warehousing. If there is no reproductive health commodity security committee, the national condom support team should advocate for the estab- lishment of one. Identify human resource capacity strengths and gaps and determine how these can be utilized or filled. Identify institutional capacity strengths and gaps and determine how these can be utilized or filled. Develop, obtain or adapt existing training materials (such as manuals, guidelines and demonstration models). Train trainers, drawing from the public and private sectors, civil society and social market- [hi$�;dikh[�ijWdZWhZi�Wh[�c[j�WdZ�support is maintained. Cascade training to service providers at different levels (for example, at the provincial, district and community level) and ensure quality of training. STEP 7 Strengthen human resources and institutional capacity Conduct formative research, including market research, on preferences, target audience segmentation and values and perceptions that influence the use of male and female condoms. Develop a communication strategy that includes key messages, target audiences, and channels for stimulating and sustaining demand. ;cfbeo�Yh[Wj_l[�WdZ�dedjhWZ_j_edWb�ekjb[ji�\eh�� � promoting and distributing condoms (such as condom dispensers, hair salons and youth centres). Stimulate social mobilization of communities to ensure a supportive environment for male and female condoms. STEP 8 Create and sustain demand for condoms IMPLEMENTATION PHASE 6 STEP 9 Strengthen advocacy and engage the media Initiate policy and regulatory analysis and dialogue. � <hec�j^[�i_jkWj_ed�WdWboi_i"�_Z[dj_\o�feb_Yo� issues that require advocacy for change. � >ebZ�W�ijWa[^ebZ[hi�c[[j_d]�je�h[l_[m� policy issues and start the dialogue process. ?Z[dj_\o�WdZ�ijh[d]j^[d�YedZec�¾Y^Wcf_edi¿$ � 9^Wcf_edi�cWo�X[�\ekdZ�_d�]el[hdc[dj"� civil society, and among those providing reproductive health/family planning or HIV services or implementing related programmes. � Ijh[d]j^[d�j[Y^d_YWb�WdZ�WZleYWYo�ia_bbi�e\�� � condom champions through training. Build coalitions and partnerships (through networking and engagement with civil society and other segments of society). � ?Z[dj_\o�W�m_Z[�hWd][�e\�ijWa[^ebZ[hi� interested in working to improve the policy environment. � ;ijWXb_i^�W�Yecced�]eWb"�c_ii_ed�ijWj[c[dj"��� roles and responsibilities, and communica- tion process. � :[l[bef�WdZ�_cfb[c[dj�j^[�WZleYWYo�fbWd$ Coordinate media outreach and capacity-building. Develop a communication strategy to engage the media. Provide sensitization and skills-building for journalists and members of the mass media. STEP 10 Monitor programme implementation routinely, conduct research and evaluate outcomes Incorporate the CCP monitoring & evaluation \hWc[meha�_dje�j^[�dWj_edWb�C���;�\hWc[meha$ Review and update operational plan indicators. Identify research areas and conduct research to support programme implementation. ;ijWXb_i^�XWi[b_d[i$ ��?Z[dj_\o�c_b[ijed[i�WdZ�_dj[dZ[Z�jWh][ji$ ��KfZWj[�XWi[b_d[�ZWjW�_dZ_YWjehi�WdZ�kdZ[hjWa[�� a baseline study, as necessary. Monitor programme implementation. ��9ebb[Yj�WdZ�WdWboi[�hekj_d[�ZWjW�ed�fhe# gramme delivery among target populations (risk groups) and the various public-health interventions in which condom programming has been integrated. ��>ebZ�hkbWh�h[l_[m�WdZ�fbWdd_d]�c[[j_d]i�� � with the national condom support team. ��I^Wh[�\[[ZXWYa�\hec�j^[�h[l_[m�m_j^�_cfb[#� � menting partners. ��;dikh[�j^Wj�\[[ZXWYa�_i�ki[Z�Xo�_cfb[c[dj_d] partners to adapt, readjust and improve pro- gramme implementation. ;lWbkWj_ed ��9edZkYj�WddkWb"�c_Z#j[hc�WdZ�[dZ#e\#j[hc�� � evaluations. ��Fhel_Z[�\[[ZXWYa�\hec�[lWbkWj_edi�je�_cfb[# menting partners. ��;lWbkWj[�el[hWbb�_cfWYj�e\�j^[�dWj_edWb�ijhWjo$ 7 Condom programmes will have different objectives, based on the circumstances of a particular beYWb_jo$�;nWcfb[i�e\�feii_Xb[�fhe]hWcc[�eX`[Yj_l[i"�WYj_l_j_[i�WdZ�Z[b_l[hWXb[i�\ebbem0 Establishing a National Programme 8 Hire service providers, as needed, and train and equip them to educate, counsel and follow up with people who use male and female condoms. ;ZkYWj[�mec[d�WdZ�c[d��_dYbkZ_d]�WZeb[i- cents) about HIV and other STIs; explain how barrier methods such as male and female condoms can help protect them from STIs. Improve women’s skills to negotiate safer sex when their partner(s) is reluctant to use male condoms. Increase overall uptake and sustained use of male and female condoms. Promote correct and consistent use of male and female condoms for prevention against HIV and/or unintended pregnancy. ;dikh[�j^Wj�WZ[gkWj[�dkcX[hi�WdZ�W�Yedj_dk- ous supply of male and female condoms are provided in target countries. Advocate, as necessary, for the inclusion of male and female condoms in national essen- tial drug lists. Identifying programme goals, activities and deliverables Increase the number of sex acts that are protected against STIs, including HIV, and unintended pregnancy. ;nfWdZ�WYY[ii�WdZ�ki[�e\�cWb[�WdZ�\[cWb[� condoms for dual protection in low- and middle-income countries. Make male and female condom programming an essential component of national policy guidelines and programmes for HIV/AIDS and reproductive health. PROGRAMME OBJECTIVES PROGRAMME ACTIVITIES Key deliverables will include: Strategy documents: national condom strat- egy, multi-year strategic plan, strategy on demand-creation, and a condom security plan. Tools: monitoring and evaluation framework, instruments for a baseline survey and pro- gramme evaluation. Capacity development workshops: on monitoring and evaluation, creating demand, behaviour change communication, reaching the mass media, and disseminating lessons learned. Reports: biannual progress reports and end- of-programme report. 9 Promote male and female condoms as a dual- protection method and integrate condoms into a wide range of reproductive health services and non-health services. Support inclusion of male and female condom programming into national HIV/AIDS strategies. Create or augment gender-sensitive preven- tion programmes that focus on women; ensure that these programmes incorporate informa- tion on female condoms and encourage male participation. Work with and monitor all relevant donors, foundations and international agencies to en- sure that efforts in condom programming are strategic, coordinated and sustainable. Develop specific programmes that are gender sensitive and that reach out to men and boys as partners in sexual and reproductive health. KEY DELIVERABLES Selecting countries for assistance The identification of countries to receive assistance should be undertaken in conjunction with an analysis of the problem. In epidemiological terms, there are three AIDS epidemics (see box).* The Joint UN Programme on HIV/AIDS (UNAIDS) and the World Health Organization have characterized these epidemics as low-level, concentrated and generalized. Given the dynamic nature of the epi- demic, countries can move across these categories. Within a given country, there is often a series of multiple, changing and overlapping micro-epidemics, each with its own nature (the population most affected), dynamics (patterns of change over time) and characteristics (severity of impact). An understanding of the nature, dynamics and characteristics of local epidemics is needed to ensure that HIV prevention strategies are adapted to fit local conditions (Step 2 of the 10-Step Strategic Approach to CCP). * In 2008, UNAIDS added a fourth category of epidemics. In these ‘hyperepidemic scenarios’, found only in a few Southern African countries to date, HIV prevalence exceeds 15 per cent in the adult population. The epidemic is driven in particular by multiple, concurrent partnerships among heterosexual couples as well as low and inconsistent condom use. Source: UNAIDS. 2008. Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access. UNAIDS: Geneva. 10 The three categories of AIDS epidemics LOW-LEVEL Principle: Although HIV infection may have existed for many years, it has not spread to a significant level in any subpopulation. Recorded infection is largely confined to individuals with high-risk behaviour such as sex workers, injecting drug users, and men having sex with men. The epidemic state suggests that networks of risk are rather diffuse or that the virus has been introduced only very recently. Numerical proxy: HIV preva- lence has not consistently exceeded 5 per cent in any defined subpopulation. CONCENTRATED Principle: HIV has spread rapidly in a defined subpopula- tion, but is not well established in the general population. The epidemic state suggests an active network of risk within the subpopulation. The future course of the epidemic is determined by the frequency and nature of links between highly infected subpopulations and the general population. Numerical proxy: HIV preva- lence is consistently over 5 per cent in at least one defined subpopulation; HIV prevalence is below 1 per cent in pregnant women in urban areas. GENERALIZED Principle: HIV is firmly estab- lished in the general population. Though subpopulations at higher risk may continue to contribute disproportion- ately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic independently of subpop- ulations at higher risk of infection. Numerical proxy: HIV preva- lence is consistently over 1 per cent in pregnant women. In low-level and concentrated HIV-prevalence settings where the epidemic is nascent, the primary focus is on those at highest risk who have been identified by epidemiological and social mapping. These highest-risk groups include marginalized and vulnerable populations. Marginalized populations Marginalized populations include sex workers, injecting drugs users, men who have sex with men and those living with HIV. Certain factors increase their vulnerability to HIV infection, including stigma and discrimination, gender inequality, poverty, lack of HIV awareness, and limited access to education, health and other services. The negative attitudes others might have towards these marginalized groups are compounded by stigma related to HIV. To make matters worse, countries frequently have laws that criminalize their behaviour and make it difficult for marginalized groups to exercise their human rights, including accessing health services. Vulnerable populations Young people are at particular risk of contracting HIV. Because of their biology and physiology, girls and young women are at least twice as susceptible to HIV infection as boys and young men. They are also more socially, culturally and economically vulnerable. Poverty, gender inequality, sexual violence, lack of economic independence and poor educational opportunities can limit their ability to choose when, how and with whom to have sex. Approximately half of all people living with HIV are women, of whom the vast majority were infected through heterosexual transmission. In sub-Saharan Africa, almost 60 per cent of adults living with HIV are women. The majority of new HIV infections in women occur in marriage or in long-term relationships with primary partners, according to UNAIDS. Vulnerable populations therefore include: ��Women, including pregnant women and women who are married or in a long-term relationship with a primary partner ��Young people, especially young women and girls. In generalized HIV epidemics, specific strategies for reaching marginalized and vulnerable populations are needed, combined with broader strategies to reach all segments of society at a sufficient scale. Targeting populations 11 1. 2. 12 Monitoring and evaluation The success of a condom programme is determined by monitoring implementation and mea- suring increases in awareness, access to and use of male and female condoms for STI/HIV prevention. These increases will be measured by the expansion of activities that result from the programme, by the uptake of condoms, by the rate of continued condom use over time and by reductions in STIs, including HIV, in subpopulations. The lessons learned and case study documents will identify strengths and weaknesses of the overall programme and of individual implementation strategies. These documents will also help to refine and adapt the programme on an ongoing basis. An annual review and needs assess- ment should be produced by the partners to review progress and to plan the subsequent year’s work plan. 13 References Global HIV Prevention Working Group. June 2007. Bringing HIV Prevention to Scale: An Urgent Global Priority. Marseille, Elliot, et al. September 2002. Cost-Effectiveness of HIV Prevention in Developing Countries. HIV InSite Knowledge Base Chapter. See: http://hivinsite.ucsf. edu/InSite?page=kb-08-01-04#S3X UNAIDS. 2005. Intensifying HIV Prevention. UNAIDS policy position paper. Geneva: UNAIDS. UNAIDS. 2008. Report on the Global AIDS Epidemic. Geneva: UNAIDS. UNAIDS website. Policy and Practice: Key populations. See: http://www.unaids. org/en/PolicyAndPractice/KeyPopulations/default.asp UNFPA, Population Council. 2003. Rapid Needs Assessment Tool for Condom Programming. New York: UNFPA. UNFPA, WHO, UNAIDS. 2004, updated in 2009. Condoms and HIV Prevention. Position Statement. New York: UNFPA. Produced by HIV/AIDS Branch/CCP UNFPA Technical Division May 2010 United Nations Population Fund 220 East 42nd Street New York, NY 10017 www.unfpa.org ISBN 978-0-89714-928-0
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