PATH Female Condom- A Powerful Tool for Protection
Publication date: 2006
Female Condom A Powerful Tool for Protection About this document After more than ten years on the market and despite the clear need, the supply and adoption of female condoms is low—signiﬁcantly t and despite the clear need, the supply and adoption of female condemupply ante the ondoon below the levels needed to have an impact on the HIV/AIDS epidemic. More than 100 experts from 15 countries met in Baltimore, mpact on the HIV/AIDS epidemic. More than 100 experts from 15 coMore than the HIV/ countr Maryland, in September 2005 at the Global Consultation on the Female Condom (GCFC) to discuss the status of the female condom e Global Consultation on the Female Condom (GCFC) to discuss the Condom ultat the status oa worldwide and to develop a plan of action to build support for the method.f action to build support for the m odo build su 1 A key goal of this plan is to gather the support ofkey goal of this plaan is to gatherg donors, policymakers, and women’s health advocates worldwide to make the case for immediate, widespread promotion and ’s health advocates worldwide to make the case for immedikealth advocates te, widespread prsp distribution of female condoms as an important way to protect women, men, families, and communities around the world. Thisan important way to protect women, men,nortant way mmunities around ts arou document answers key questions about the female condom and builds on the momentum created at the GCFC by presenting about the female condom and builds onthe eated at the GCFC byhe GC evidence of the female condom’s effectiveness and impact, identifying current challenges to wider use, and indicating the steps that s effectiveness and impact, identifyingectiv wider use, and indicaer use, and need to be taken now to develop strong female condom programs worldwide. op strong female ctro This document was funded by UNFPA and written by Barbara C. Shane, consultant, with assistance from Maggie Kilbourne-Brook,b ultant, with assistance from Maggie e from M Patricia S. Coffey, and other PATH staff. Production assistance for this document was provided by Cindy Rider, and the design is byment was provided by Cindy Rider, ant ndy R Katrina Perekrestenko. The material presented in this document is based on presentations and discussions at the GCFC. The opinions n presentations and discussions at thse ssio expressed herein do not necessarily reﬂect the views of UNFPA. We thank the following individuals for their review of this document:k the following individuals for their review of this document:ollow fo Mags Beksinska, Martha Brady, Bruce Campbell, Bidia Deperthes, Nicole Gray, Patrick Friel, Theresa Hatzell Hoke, Lori Heise, JodiGray, Patrick Friel, Theresa Hatzell Hoke, Loatrick e Jacobson, Judy Manning, Suman Mehta, Anne Philpott, Beth Robinson, Kathleen Shears, Jacqueline Sherris, Jeff Spieler, MitchellKathleen Shears, Jacqueline Sherris, Jefhleen Sh er, Mitchell Warren, and Heidi Worley. PATH 1455 NW Leary Way Seattle, WA 98107 USA 206.285.3500206.28 www.path.orgpath United Nations Population Fundat un 220 East 42nd St. New York, NY 10017 USAUS 212.297.5000 www.unfpa.org Suggested citation: PATH, UNFPA. Female Condom: A Powerful Tool for Protectionon. Seattle: UNFPA, PATH; 2006. Seattle: UNFPA, PATHe Copyright © 2006, Program for Appropriate Technology in Health (PATH) and United Nations Population Fund (UNFPA).PATH) and United Nations Population Fund (UNFPA). All rights reserved. “Female condoms are of enormous importance tonormous impom the ﬁght against AIDS because they are the onlyause they are the they a existing, effective female-controlled preventivecontrolled preventiveed p tool against HIV and other STIs. However, their STIs. However, theirHowever, use has remained frustratingly and tragically ly d tragica low, despite growing demand from womenfrom men themselves. The barriers of price and supply musters of price and supply mu be overcome. Female condoms must be brought ondoms must be brought within the reach of all women as a core partwomen as a core pmen as a of the world’s commitment to moving towards nt to moving towamovin universal access to HIV prevention, treatment, vention, treatmenttion, treatm care, and support.” — Dr. Peter Piot, Executive Director, UNAIDS Executive Director, UNAIDS Broad support from the global health community “We must increase access to female-controlled methods of prevention to ensure that women methods of have life-saving tools, such as female condoms.”sae l — Dr. Thoraya Obaid, Executive Director, UNFPAT “The female condom works. It is effective in ks. It is effective in s effe preventing pregnancy and STIs, including HIV. STIs, including HIV. uding H When it is offered with good counseling andd coounseling and support, female condom availability results inbility in signiﬁcantly safer sex … More choice equals more equals more protection. It’s that simple. Increased choice helps to empower women. As part of a rights-based approach to health care, women should by right have access to female condoms.” — Dr. Steve Sinding, Director General, International Planned Parenthood Federation Table of contents Overview. 1 Unprecedented need. 3 Protection for all . 5 Reducing infections . 7 Dual protection. 9 Saving women’s lives .11 Cost-effectiveness.13 Challenges .15 Increasing demand . 19 Prospects for new products. 23 Priorities . 25 A ﬁnal word . 28 References. 29 Selected resources. 31 Overview Millions of couples worldwide need effective protection against sexually transmitted infectionsfective protection against sexually transmitted infectionsprotection against sexu (STIs), including HIV, and pregnancy. Treatment and care efforts are expanding worldwide, but they tment and care efforts are expanding worldwide, but eydwe effo cannot keep up with the spread of the HIV/AIDS epidemic, especially among women and girls. The AIDS epidemic, especially among women and girls. hen em female condom is an effective STI and pregnancy prevention technology available now that enablesprevention technology available now that enab se now couples to reduce their risks. Research shows that the method is comparable to the male condomod is comparable to the male condomhe mam in its effectiveness in preventing pregnancy and STIs. Access to the female condom can increase the cess to the female condom can increase the dom canthe proportion of couples having protected sex and offers a lifesaving alternative when male condoms are a lifesaving alternative when male condomswhenaving not used. Although female condoms have been introduced in many countries, their supply and uptake inntries, their supply and up e in heir sup countries hardest hit by the HIV/AIDS epidemic is woefully inadequate. In 2005, only 14 million equate. In 2005, only 14 ion ate. In 200 female condoms were available for distribution, while 6 to 9 billion male condoms were providedon male condoms were idedcondom worldwide. Greater investment by the private and public sectors and support from the donor d support from the doom community are urgently needed to make the female condom an affordable option. While new an affordable option. While n w female condom products being developed offer more choice and may overcome some of theand may overcome some of the problems reported by current users, these products face ﬁnancial and regulatory barriers that slowial and regulatory barriers that sloand regu their path to market. Advocacy for the female condom, from the community level upwards, iscommunity level upwards, ismmunity needed to stimulate demand and increase access and availability. Research that provides more data Research that provides more datah that prone on the method’s impact and cost-effectiveness will help promote the female condom. female condomon The female condom is not a promise on the horizon, but an effective, female-initiated method ale-initiated method e feT available now that can protect women from pregnancy and STIs. It is a an important technology that is a an important technology bleav needs to be given a more prominent role in reproductive health programs and included in STI/HIV grams and included in STI/HIV o bneed and pregnancy prevention efforts worldwide.nand 2 Millions of women worldwide suffer from STIs—allns of women worldwide suffe of which are preventable, but many of which are not hich are preventable, but many oeventable, but m curable. Almost half of the 39 million adults around theable. Almost half of the 39 million aalf of the 39 m world infected with HIV are women—up from aboutworld infected with HIV are women—up HIV are women— one-third in 1985.one-third in 1985.2,32 Young women are most at risk.are mo Half of all new HIV infections occur in young people (15alf of all new HIV infections occur to 24 years old). Other STIs also take a toll worldwide,to 24 years old). Othe and some can make those infected more vulnerablesome can make thme ca to HIV infection. According to the latest World HealthV infection. Accordinfection. Acc Organization (WHO) estimates, 340 million new cases nization (WHO) estimion (WH of curable STIs occur every year. able STIs occur everys occur Biology, gender roles, sexual norms, and inequalities ender roles, sexuse in access to resources and decision-making power putesources and women and girls at greater risk of infection than menreater and boys. Many women have insufﬁcient informationav about sexual and reproductive health and do not understand the risks associated with their own or their partners’ sexual behaviors. Many of those who do recognize their vulnerability are powerless to protect themselves. Women who receive information and counseling, and who learn to use the female condom, can protect themselves even if their partners refuse to use a male condom. Yes.Yes The need for effective alternativesThe need for effective alternated to the male condom is critical to protect male condom is critical to protectto the ritical to pr women and couples from STIs andand couples from STIs andwomen rom STIs unintended pregnancy.unintended pregnint ancy. UNPRECEDENTED NEED Is there a need for the female condom? The need for effective options to protect The ne women’s health and future fertility is urgent. Currently, the only protective methods against STIs are the male and the female condom. Since the advent of the HIV/AIDS epidemic, the female condom is the only new technology developed and approved that protects against STIs (see box). Not only can effective female condom programs help women and couples reduce their risks for diseases and unintended pregnancies now, strong introduction programs can also help pave the way for the introduction of other new protection methods, such as cervical barriers and microbicides, which will become available in the next decade. The female condom The most widely distributed female condom, the FC Female Condom®, is the only female condom currently approved by the US Food and Drug Administration and distributed by major donor agencies.5 It is a soft, strong, transparent polyurethane sheath about the same length as a male condom, but with ﬂexible rings at both ends. It can be inserted into the vagina several hours prior to sexual intercourse and can remain in place after ejaculation. It provides a protective barrier between the penis and the cervix, the vagina, and parts of the external female genitalia. Polyurethane is a thin, odorless material that transfers heat better than latex. The female condom is prelubricated with a silicone-based, non-spermicidal lubricant. It has a shelf life of ﬁve years. Studies show that some women like the female condom because it gives them greater control over safe-sex negotiation, is effective for STI and pregnancy prevention, is easy to use, increases sexual pleasure, and is a good option for men who do not like male condoms. However, other women report dissatisfaction with the female condom because of discomfort during sex, the need to get a partner’s consent, difﬁculties in use, aesthetic concerns, noise, sensitivity to polyurethane, and/or cost. New female condom designs that address these problems are being developed. A new condom from the Female Health Company, FC2, may be available in 2006; other new designs are several years away. FC Female Condom is a registered trademark of Female Health Company. 4 “A place for female condomsA place for female condomsom ? It is not whether there is a placehether there is a placa p but WHAT is the placeWHAT is the placth ?”4 — UK Department for Internationalrtment for Internatioor Intern— UK D Development Health Advisor in Chinat Health Advisor in Cdvievelopm “This female condom in question … I have been hearing of it but I don’t actually believe it exists … I want to be convinced there is something like the female condom.”6 — Chinazo Nkechi 5 PROTECTION FOR ALL Can all women use the female condom? Yes. All women at risk for STIs and/or pregnancy are appropriate users of the female condom. It is especially suitable for e f r women who are unable—for a variety of reasons—to depend on male condoms and who need protection from STIs.7 Women want the means to protect themselves from unplanned pregnancy andnn STIs, and they are eager to try products ager t that offer protection. Early female condom on. Early E introduction efforts were targeted to orts were tare commercial sex workers (CSWs), because workers (CSWrs (C they are at high risk for HIV and other STIsh risk for HIV anor H and have an obvious need for a female-bvious need for aous nee initiated method of protection. The female ed method of protection. of protec condom is well accepted by CSWs in many dom is well accepted by CSepted b countries, especially as an option when clients ntries, especially as an option when clients s a refuse to use male condoms. Training thatuse to use male condoms. Trainint tnd includes insertion practice has contributed tocludes insertion practice has coes ins ibuted to acceptance of the female condom by CSWs.ceptance of the female connce by CS As the global HIV/AIDS epidemic has s the global HIV/AIDS epide global mic has evolved, so too have the populations at risk.olved, so too have the populations at risk., so to About three of every four HIV infections inAbout three of every four HIV infections ee developing countries are transmitted throughdeveloping countries are trco heterosexual intercourse. The majority of erosexual intercourse. h new HIV infections in women occur withinHIV infections in women occur within marriage or long-term relationships with ge or long-term relationm with primary partners.y partnerprim 2 In southern India, an sout rn India, signiﬁcant proportion of new infections occurs ant proportion ofsign ew infections occurs among married women, many of whom haveg married women, mam of whom been infected by husbands who frequented nfected by husbands who frequented ee CSWs.CSW 22 Male clients of CSWs are infecting Male clients of CSWs are infectin their wives and girlfriends in Thailand, where r wives and girlfriends in Tha as many as one-half of new HIV infectionsas many as one-half of new HIV infectioe-half of new each year occur within marriage or regular ach year occur within marriage or reear occur within marriag partnerships.ners 2 Almost seven in ten young in ten ymost s women surveyed in Zimbabwe and Southsurveyed in Zimbabwe and Southd Africa reported having one lifetime partner, d having one lifetime partn and eight in ten had abstained from sex abstained from sexd until at least age 17. Nonetheless, four in ten7. Nonetheless, four i tenthel of these young women were HIV positive.women were HIV positivn were 2 Young, married women are the fastest-women are the fasare t growing group of HIV-positive people, and of HIV-positive people, anV-positiv it is urgent to reach them with preventive each them with preventive ch them w measures. Reaching out to these couples with ching out to these couples o unbiased, culturally appropriate information urally appropry a is an increasingly important focus of female gly importi condom programs.gram Married women can use the female condom’s effectiveness in pregnancy protection to promote its use to their husbands, who may be reticent to use a condom, or who may associate condom use only with extramarital sex. In Zimbabwe, the female condom has been marketed successfully to couples as the “Care Contraceptive Sheath,” thus distancing the product from any stigma associated with male condoms and STIs and building an image of acceptability of this method among couples who “care.” 6 Does the female condom prevent transmission of STIs? Yes. Evidence from laboratory and population-based studies shows the female condom is at least as effective as the male condom at t preventing STIs.TIs. Several laboratory studies show that the everal laboratory studies show that the borato ow material used in female condoms, polyurethane,material used in female condoms, used is an effective barrier against many commonis an effective barrier against many commoc STIs, including HIV. A test simulating sexualncluding HIV. A test simulating sexual intercourse found the female condom wascourse found the female condom impervious to HIV.mpervious to HIV.88 A test of the permeability A test the permeability of female condoms to gas, liquid, and theof female condoms to gas, li d, and th ǗǗX174 virus (a virus smaller than HIV) similarly X174 virus (a virus smaller than HIV) similarly found them to be impermeable barriers.d them to be impermeable barrem 9 Based on these laboratory tests, the study authorsese laboratory testaborat concluded that female condoms can provide a uded that female cothat female highly protective barrier for STI prevention and highly protective barrier fove b contraception. ontrace An additional estimate of the effectiveness ofadditional estimate of e female condoms in preventing HIV transmission male condoms in prevenf has been derived from the method’s s been derived from the effectiveness for pregnancy prevention and ffe estimates of the risk of HIV infection per actes of sexual intercourse. According to one such scenario, perfect use of the female condom for a year by a woman having sexual intercourse 7 REDUCING INFECTIONS 8 of male condoms.14 Consistent use of theof thet female condom by women in the United e U t States provided complete protection from ect fr trichomoniasis reinfection.15 A review of studies of the male condomle ondom determined that, in typical use, the male typical use e male condom results in an 80 percent reductionn 80 percen ductio in HIV incidence.16 While no studies haveWhile no studh av evaluated the speciﬁc HIV prevention ciﬁc HIV preventioH effectiveness of the female condom, it is likely he female condom, it is likely male that the female condom provides at least the ondom provides at least them p same level of protection as the male condom. of protection as the male condotion a Because it covers the base of the penis andt covers the base of the penis andbase o some of the external female genitalia and is the external female genitalia and is male more resistant to tears, the female condomsistant to tears, the female condoma e f may offer better protection against genital fer better protection against genitaetter ulcer diseases.is es “. the female condom is not a luxury to many women,“. the female condom is not a luxury to many womcon ry to many especially in Africa and probably elsewhere too. It is aally in Africa and probably elsewhere too. It iAfric necessity that determines life or death.”sity that determines life or dhat de — Daisy Nyamukapa, UNFPA ZimbabweDaisy Nyamukapa, UNFPA Ziy apa, UNF twice a week with an HIV-infected partner could reduce her risk of acquiring HIV by more than 90 percent.10 Even if the woman only used a female condom half of the time, her risk of HIV infection in one year would still be reduced by 46 percent. Several small studies, including the few randomized, controlled trials on female condom use, indicate that female condoms confer as much protection from STIs as male condoms. Studies in Kenya, Thailand, and the United States found that the prevalence of STIs declined by about the same amount among women who were given female or male condoms as among those who were given only male condoms.11–13 The additional protection offered by female condoms is shown in recent data from Madagascar, where STI prevalence declined by 13 percent among sex workers a year after female condoms were added to the distribution 9 DUAL PROTECTION Does the female condom offer dual protection against pregnancy and STIs? Yes. The female condom is the only woman-initiated method of dual protection against STIs and pregnancy available. Several studies show that the femaletudies showes condom provides about the same m provides abouides protection from pregnancy as theion from pregnam p male condom. WHO-supportedondom. WHO-supW studies comparing the effectiveness comparing the efmparing t of female and male condoms showle and male condoms showd male that the two types of condoms are that the two types of condoms apes substantially equivalent in preventing ubstantially equivalent in p enting iv unintended pregnancies. Effectiveness tended pregnancies. Eni tiveness rates for typical use among studytypical use amotes fo tudy participants in China, Panama, s in China, Panticip ma, and Nigeria ranged from 94 to 98 ranged fromnd Nig 94 percent for the female condom percent for the female condom rcent fo and from 92 to 96 percent for the and from 92 to 96 perceom 9 male condom.ale condomdo 17 Previous studies hadous estimated the female condom to beestimated the female condom to be 79 percent effective in typical use, percent effective in typical 7 compared to 85 percent for male pared to 85 percent foc ale condoms, 80 percent for diaphragms, ms, 80 percent foc diaphragms, and 71 percent for spermicides.percent for spermicand 1818 Promotion of female condoms foron of female condomsProm dual protection is particularly relevant tection is particularly relevant ual in countries where married women ries where married womeou are increasingly at risk of infection. are increasingly at risk of The female condom expands thee condom expands the opportunities for lifesaving dual es for lifesav ng dual protection. UNFPA Global Female Condom Initiative The most comprehensive program to promote the female condom as a dual protection method is the Global Female Condom Initiative launched by UNFPA in 2005, which aims to scale up female condom programming in at least 23 countries.19 At the country level, UNFPA has helped establish condom technical working groups and is working with government and other stakeholders to develop and implement country-driven strategies for integrating female condoms into a wide range of reproductive health services. The goals of the Female Condom Initiative are to (1) expand access to female condoms and (2) integrate female condoms as an essential component of national HIV/AIDS policy guidelines and reproductive health programs. The Initiative aims to: Increase uptake of female condoms. Empower women to negotiate safer sex with their partner(s). Promote correct and consistent use of female condoms for HIV prevention. Advocate for the inclusion of female condoms in the WHO essential drug list. • • • • 10 SAVING WOMEN’S LIVES Does the female condom have an impact on levels of protected sex? ´,W KDV DOZD\V EHHQ GLIÀFXOW IRU ZRPHQ WR have the courage of telling a man to put on a condom whenever they are having sex, but this time around they will have a chance to protect themselves.”20 — Clemente Naunje, Banja Lamtsogolo, 2006 11 The contribution of the female condom tohe contribution of the femati overall increased protection and decreased rall increased protection and decreased ov se prevalence of STIs depends on who useslence of STIs dependsp it, how correctly and consistently it is used, w correctly and coni and whether it is a substitute for the malewhether it is a substitute for the mnd condom. Many studies show that providing theom. Many studies show that providingco female condom (as part of a comprehensive ale condom (as part of a comprehensive fe t of a comp prevention strategy) results in increased levelsvention strategy) results in increased levelsp s in increased lev of protection. of protection. Protected sex amongtected sex among wsex among women in studies in theen in studies in United Statested States ans and Brazil doubled after they l dou received femceived femaale condoms and counseling on nd ccond their correct heir correct uuse.21,2221,22 In Madagascar, protectedas In Mada sex increased sex increased bby 10 percent among CSWs dueon10 perce to their use of the female condom.to their use of the female condommale co 14 Other studies of female or male condom use in studies of female or male condomale con Kenya, Zambia, the United States, Zimbabwe, e United States, t South Africa, and Nigeria found thata found th encouraging use of either method contributedhod c to increases in the proportion of protected sex acts.23–29 When both types of condoms s are available, consistent condom users oftenofte switch between use of female and male e and male condoms. These studies provide importantvide importani evidence that the female condom is not just nd a substitute for the male condom, but is complementary and contributes to increased use of both types of condoms. As has been shown for male condoms, female condoms likely offer some protection against chlamydia, gonorrhea, herpes simplex, syphilis, and human papillomavirus infections.30 Because the female condom covers more of the external female genitalia than the male condom does, it may be even more effective at preventing genital ulcer diseases—all of which can increase risk for HIV infection. Female partners of male condom users are less likely to get cervicalare les cancer, and it is plausible that the same nd it is plaus p protection is provided by female condoms.ction is providpro 31 More research is needed to determine the ore research is nerch disease-speciﬁc protection offered by thedisease-speciﬁc prose-speciﬁc female condom, especially to safeguard thefemale condom, esale condo reproductive health and future fertility of reproductive healtoduc young women.n.g wo Yes. Effective female condom interventions can increase theEffective female condomale proportion of protected sex acts and decrease STI prevalence.rtion of protected sex o cted 12 Is the female condom cost-effective? COST-EFFECTIVENESS Yes.Yes. Modeling exercises have shown that when the female condomdeling exercises haxercis M is offered as part of a well-planned STI and pregnancy preventionis offered as part of a well-plf a well-ffered program, it is a cost-effective public health intervention.rogram, it is a cost-effectivst-em, Health economists have developed models toonomists have deHealt estimate the relative beneﬁt of female condome relative beneﬁt of female condomtimate investment compared with other costs of STI/ompared with other c s ofnvestment HIV prevention and treatment. Such models HIV prevention and treatment. S models ventio can help donors, health decision-makers, and n help donors, health decisio makers, and program managers better understand theprogram managers better understand potential contribution of female condoms toential contribution of female condoms toe safeguarding health and reducing negative ng health and reducing negative safeg impacts of unprotected sex. In one such model nprotected sex. In one such modmpact commissioned by the Female Health Company, by the Female Health Company, mission substantial cost savings to the health sector substantial cost savings to the heal or ubstantial co were estimated based on different use scenarios were estimated based on differ nt use scenarioated in South Africa and Brazil of their new female outh Africa and Brazil of their ew female condom, FC2.32 For example, the model estimatedample, the mod estimate that in South Africa, assuming a low uptake of uming a low uptake of 4 million (at an estimated unit cost of US$0.77 un for product, distribution, training, and education) rain the female condom would prevent 1,740 HIVpre infections, with a net savings to the health care gs to system of about $980,000. Another type of Ano model estimates that an investment of $4,000 for female condoms distributed to 1,000 CSWs in rural South Africa would prevent many cases of HIV, syphilis, and gonorrhea, yielding net savings to the health sector of just over $9,000.33 These types of models suggest that female condom programs can be highly cost-effective and offer signiﬁcant protection to women and men. The additional beneﬁts associated with prevention of pregnancy—and prevention ofp mother-to-child transmission of HIV—have not been quantiﬁed in these models, but they would make the cost-beneﬁt analysis of the female condom even stronger. In recent years, the international community mun has focused on improving access to treatmentrea nt of HIV. While the gains made in treatment are de in treatment are laudable, they should not come at the expense la come at th expense of prevention services, which are estimated to beof p which are est ted to 28 times more cost-effective than treatment.time fective than treiv ent.34 34 Female condom programming is far less F gramming is far lem expensive than many other HIV/AIDS program ny other HIV/AIDS program er H og inputs, such as antiretroviral therapy, which, at ch as antiretroviral therapy, which, roviral commercial prices, can cost US$300 to $1,200cial prices, can cost US$300 to $1,200cost U per user per year in developing countries.r per year in developing countrieselopin 35 Even at greatly reduced prices for antiretroviral at greatly reduced prices for antiretrovea ric ral therapy, such as those negotiated by the Clintonapy, such as those negotiated by the Clich a go Foundation HIV/AIDS Initiative, the costs ndation HIV/AIDS Initiative, the costs n HI associated with treatment will grow substantially.ociated with treatment will grow subiated w The female condom is an important preventionfemale condom is an important pmale con tool, and its use along with antiretroviral therapy, and its use along with antiretroviral therapyd its us is one way to efﬁciently and effectively combine e way to efﬁciently and effectiveto prevention and treatment.ntion and treatmena 14 Are there challenges to increasing access to and use of the female condom? 15 CHALLENGES 16 With so many women’s lives depending on an effective prevention option, hopes andtion, hopes and expectations for the female condom have beenmale condom have beenve high. While research shows that the femalesh t the fem condom does provide STI and pregnancy vide TI and pregna protection, like all user-dependent methods, its ll user-dependent methodsependent m effectiveness relies on correct and consistent elies on correct and consisn correct and use and good communication betweenood communication betweeomm partners. As with all new methods, counseling, As with all new methods, counseling practice, and peer support lead to greatere, and a r comfort and conﬁdence in use of the femalert and con condom. Experience in many diverse settings om. ExperienExpe shows that women have learned to use thews that woment w female condom successfully for protection.le condom succondo The challenges of introducing the femaleThe challenges of introducing the femahe fnges condom have been compounded by negativecondom have been compounded by poundee perceptions of barrier methods. Some donors, rceptions of barrier methods. Sompe ethods. f program managers, and providers think thatm managers, and providersprog d pro women are not willing to learn the steps are not willing to learn thom ng to lea necessary for insertion, including touching their for insertion, includinnecessa genitals, or to talk with their partners aboutgenitals, or to talk witals condom use. Similar obstacles were proposedondom use. Similar obstaclesm for other vaginal products, such as tampons,for other vaginal products, such as ta (the feminine hygiene product designed to he feminine hygiene product designed duct absorb menstrual blood), which took almostorb menstrual blood), which took almostood), which took a 20 years to be widely accepted.ars to be widely20 ccep 3636 The tamponhe ta faced preconceived health care provider preconceived health care provfac biases and slow user uptake similar to those slow user uptake similar to associated with the female condom, but it isciated with the female condom, buom, now a well-accepted product used by many now a well-accepted product used by muct usedwe women. These potential obstacles could be ese potential obstacles coustaclewomen. viewed as opportunities for women to learn opportunities for women tos for womewed about their anatomy and become comfortable eir anatomy and become comy and becomabout with their bodies.eir bodiewith By teaching women to become familiar withBy teaching women to beco their bodies and to gain conﬁdence usinges and to vaginal methods, the female condom can ease the acceptance of other female-initiated products currently being developed, such as new cervical barriers and microbicides, which also will require insertion into the vagina. Providers inﬂuence acceptance of new methods by their attitudes and by the type of information they provide to clients. Stronger efforts must be made to ensure that providers convey accurate, unbiased information about female condoms to their clients. Another challenge cited as hindering the uptake of the female condom is the product cost, especially compared to the male condom (see boxes, next pages). New methods often cost more than existing products, especially until demand reaches a level that encourages Yes. Expectations of uptake and impact may have been too ons of uptake and impact may have been toave be optimistic, given the challenges of introducing a new product.the challenges of introducing a new prodw pe challenges o economies of scale in production and stimulates competition. Until this occurs for the female condom, stakeholders need to advocate for sufﬁcient ﬁnancial support to make the method widely available at low cost. Other new prevention methods under development, such as microbicides, are also expected to cost substantially more than male condoms, especially for packaging and applicators. However, research and development proceed, because the need is so great, and it is assumed that governments will provide production incentives and that donors and governments will purchase in bulk and build on existing distribution systems for product delivery. Given the small-scale programming of the female condom to date, it has been difﬁcult to show the method’s public health impact. However, pilot projects do show that making the female condom available within the context of a well-supported prevention program increases use of both female and male condoms. The female condom can contribute in many ways to improved health if programmed appropriately.38 In addition to reducing a woman’s risk of disease and pregnancy, it can lead to women’s increased knowledge of their bodies, improved sexual communication and negotiation skills, and empowerment. These beneﬁts are difﬁcult to measure, but they can have signiﬁcant impact on women’s overall quality of life. 17 Cost of the female condom One of the obstacles to more widespread distribution and use of the female condom is the high cost of the current product, especially compared to the male condom. The FC Female Condom is available to donor programs through an agreement with the Joint United Nations Programme on HIV/AIDS at a cost of £0.38 per unit (~US$0.66), or 22 times the cost of a male condom ($0.03 per unit). The discrepancy is somewhat less when the costs of delivering female and male condoms through a comprehensive STI/HIV prevention program (training, advocacy, promotion, marketing, distribution, and monitoring) are added. For example, using data from all its social marketing programs, Population Services International (PSI) estimates that the “fully loaded” unit cost (product and program costs minus income generated) for the female condom in 2005 was $1.28, 12 times greater than the fully loaded cost for the male condom ($0.11).37 The good news is that whereas the fully loaded cost for male condom programming has stabilized, the program cost for female condoms continues to drop. The current cost of $1.28 is a decrease of almost two-thirds from the $2.96 cost to procure and program female condoms in 2000. Programming costs tend to decrease over time, as programs mature and products gain familiarity and wider distribution. PSI’s social marketing programs sold 867 million male condoms in 2004, a volume that allowed immense cost efﬁciencies, in comparison with sales of only 2 million female condoms. As the demand for female condoms increases worldwide, so will sales, reducing the unit cost of purchasing female condoms. And as programs mature and product awareness grows, the need for intensive promotion should lessen, further decreasing the cost of delivering female condoms to populations where they are needed. Reuse of the female condom Reuse of the female condom has been proposed as a way to make the method more affordable now and increase its acceptability. Although the FC Female Condom is designed as a single-use product, there have been reports of reuse. In Zimbabwe, 2.2 percent of users in a study reported reusing the female condom for reasons of cost, inadequate supply, saving time, and mere experimentation.41 In 2000, WHO developed a draft protocol for reuse and commissioned research to test the safety and effectiveness of reused female condoms. Two years later, WHO issued a statement saying it does not recommend or promote reuse of female condoms, but it did publish a draft protocol that includes disinfecting, washing, drying, storing, and relubricating female condoms intended for reuse.42 While not advocating reuse, WHO has said the ﬁnal decisions must be made locally, given the diversity of cultural, social, and personal factors that inﬂuence use. It is unclear how much reuse currently takes place worldwide—and whether there is any increased risk for the woman and/or her partner—but more research on this option, including simpliﬁed disinfection protocols and the potential for reuse of the new FC2, are needed. Studies are under way to evaluate a simpliﬁed cleaning protocol. “If we have this new condom, wehave thav will get our men to use it … It will et our menur m help us a lot.”u lot. 39 — Female participant in group discussion near emale participant in group discussion near le part Durban, South Africa, 1995rban, South Africa, 19951 “We can create providers … “We can create proWe c der who understand how to talk to who understand how to talk to o u w to ta women about their bodies [and] women about their bodies [aomen a we can train women about we can train women can tr their bodies … We can do thatheir bodies … We codi with the female condom todaywith the female condom tod yem DQGQG LWLW ZLOO EHQHÀWEHQHÀW PDOHPDOH FRQGRPGRP programs, female programs, andams, female propro grams, and microbicides introduction.”cides introdumic on ”4040 — Key informant, 2004— Key informant, 2004 18 Are there feasible strategies for increasing demand and access? 19 INCREASING DEMAND 20 Worldwide orders for female condoms have not changed signiﬁcantly during the last three years, as evidenced by steady sales data from Female Health Company.5 But consistent, large sales in South Africa and Brazil show what is possible with investments in programming (see boxes, next pages). There is a need for greater demand at the community level to gain the attention of local decision-makers who handle procurement and programming. Private- and public-sector donors, as well as ministries of health and program managers, need to hear from those who stand to beneﬁt from use of the female condom. The experience in Zimbabwe—where women’s groups collected more than 30,000 signatures 30,000 signat from women demanding access to the female access to the f m condom, resulting in the government’she government’sov importation of the female condom—shows theemale condom—sc s th power of local groups. local group Global and grassroots advocacy strategies arebal and grassroots advocacy strategies ares advo e needed to make the case for female condoms. eeded to make the case for female condoto ase fo Well-coordinated efforts to reach decision-Well-coordinated efforts to reach decision-ordin ts t makers with key messages are needed tomakers with key messages are needed tomakers wit ag raise awareness and respond to questions ss and respond to q ions se awaren and concerns. Involving professional and concerns. Involving professiod concerns. health associations, policymakers, programhealth associations, policymakers progration managers, service providers, community nagers, service providers, community leaders, and local women’s and youthleaders, and local women’s and y groups in coordinated efforts to advocategroups in coordinated efforts to a for increased funding, support, and for increased funding, support, anncreased programming for the female condomogramming for the female condoming for th will better voice the need for this type ofbetter voice the need for this type ofce the n protection. tion. Far greater education and outreach is needed ducation and outreach is ne to increase the demand for female condoms ondo by potential users. This involves reaching outby ng ou to women and men who are not normally t ally the focus of condom promotion. Targetingt g the female condom to young people can help them incorporate this risk-reducing strategy early in their sexual experience to protect against pregnancy, disease, and infertility (a sequela of STIs such as chlamydia). Men need to be included in female condom education and outreach efforts to help overcome partner opposition, effo an important reason given by some womenmpor for discontinuing use of the method.ntinfor disco Yes. Increased promotion, wider distribution, better integration with otherstribution, better integration witgrationbution, b health programs, and reaching out to at-risk couples will stimulate demandat-risk couples will stimulate demulatisk coupl for female condoms and contribute to improved access.proved access.cce Focusing on these groups and others whothese groups aro may be at risk, such as women with multiplesk, such as womh as w partners, intravenous drug users, HIV-discordantrtners, intravenous drug uenous d couples, and HIV-positive women, as well asouples, and HIV-positive woIV-pos couples in stable partnerships, can increase the couples in stable partnershie partn demand and provide increased protection to theand and provide increaem ide most vulnerable populations.vulnerable populatio po Integrating female condom programming ng female condomteg ogramming with other services, including family planning, er services, including family planning, with g family p reproductive health, voluntary HIV counselingctive health, voluntary HIV counselieprod untary HIV cou and treatment, preventing mother-to-child atment, preventing mother-to-chid t nting mot transmission of HIV, antiretroviral treatment transmission of HIV, antiretroviral treasm programs, and antenatal care, can be cost-rograms, and antenatal care, can efﬁcient and increase access to the method cient and incre for these potential users. The combined forces hese potential users. of these programs can build capacity and helpese programs can build cap institutionalize female-initiated methods and tutionalize female-initiated metnitiated facilitate the introduction of other women’s cilitate the introduction of other wotroduction protection options as they become available.protection options as they become avaas they become All women need access to a range of methodsAll women need access to a range of met to protect themselves from unintended tect themselves from un pregnancy and STIs. Decades of family-planning research have shown that increasing the choice of methods leads to increases in overall use. The greater the number of choices, the greater the likelihood that couples will use protection for every sexual act. Supporting female condom programming efforts that include information, practical training, and low-cost supplies will help make the female condom acceptable and available to all who can beneﬁt from its protection.38 It is not a question of whether the female condom is a better method than Promoting dual protection in South Africa South Africa has one of the largest female condom programs in the world. In 2004, 1.4 million female condoms were distributed through the national program. The female condom was introduced in the country in 1998 through a pilot program targeting distribution through family-planning clinics, CSW sites, and a social marketing program in eight of nine provinces.28 The introduction strategy included provider training, information pamphlets for clients, monitoring and analysis of condom distribution, and quality assurance and supervision visits. Interviews with female condom users following the introduction showed that most female condom accepters were young (age 20 to 29), were current users of hormonal contraceptives, and mainly adopted the female condom for the additional beneﬁt of STI/HIV protection. The female condom program in South Africa is guided by a government barrier methods task force that includes all the key female condom stakeholders and works to ensure consistent supply of high-quality condoms to all provinces. The program’s success is also due to the coordinated, structured introduction strategy; well-monitored and controlled supply of female condoms; and comprehensive training of providers on female condom and dual protection. The program is now working to keep pace with demand, as well as stimulate greater involvement from the private sector. 21 the male condom, diaphragm, or other family-planning method, but of how to give a woman options. With more than one option, she can choose the method that best ﬁts her (and her partner’s) reproductive health needs. “… there is generalized lack ofe is generalizeener“… the political commitment on the political commitmentmitmtica part of national leaders topart of national leadal support the procurement, support the procurement, distribution and promotion ofution and promo on ofdistri female condoms …”female condoms …”male c 66 — Maxwell Madzikanga— Maxwell Madzikanw Reaching out to high-risk women in Brazil The female condom is a widely recognized STI/HIV prevention method in Brazil. The government ﬁrst introduced female condoms following a large-scale acceptability study in 1999, targeting the most vulnerable groups, including CSWs, HIV-positive women, women with STIs, female drug users, and women at risk from violence. Social marketing of female condoms had begun two years earlier in the private sector by DKT do Brasil. In 2000 and 2001, almost 2 million female condoms were distributed at no or low cost through the public and private sectors. After ﬁve years, knowledge and acceptance are widespread, and distribution of the female condom has been highly effective in speciﬁc groups, like CSWs. Training service providers how to introduce and demonstrate use of the female condom and reaching out to women and men through community-based organizations have been key elements in the successful introduction of the female condom in Brazil. The program is now faced with the challenge of increasing distribution to meet the urgent need to protect vulnerable populations. Although 4 million female condoms were distributed in 2003 and 2004, Ministry of Health ofﬁcials believe that distribution should increase ﬁve-fold to better meet the need.44 22 Are there prospects for new female condom products? “We call on governments to ensure that the female condom is marketed to women in local communities and promoted as an effective method to prevent HIV/AIDS and sexually transmitted infections.”45 — Dr. Musimbi Kanyoro, World YWCA 23 PROSPECTS FOR NEW PRODUCTS Most global experience and published global experience and published Mos information currently available about the femaleinformation currently available anf condom comes from just one product, the FC condom comes from just one produ just Female Condom, manufactured by the Femaleemale Condom, manufactured by thufactured b Health Company (FHC). Two other femaleHealth Company (FHC). Two other feTwo oth condoms, the V’Amour Female Condom and thecondoms, the V’Amour Female Condo ale Con Natural Sensation Panty Condom, are in limited l Sensation Panty Condom, are iensa marketing outside the United States, but theyting outside the United States, bug outsid have not been approved by the US Food and not been approvbeen app Drug Administration or included in procurement Administration oistra by major donor agencies.r donor agenca 46 FHC has developed a second-generation female condom, the FC2,generation ti made of synthetic latex, which should allow for etic la price reductions as production volumes increase. as At the request of the Joint United Nations Programme on HIV/AIDS, UNFPA is negotiating a price agreement with FHC for large-volume procurement of FC2. FHC hopes to develop a coalition of regional buyers to enable cost savings through bulk regional procurement. Nonetheless, to achieve even a 50 percent price reduction (US$0.31), global sales and bulk purchasing will have to increase to 200 million units—more than 14 times the total 2005 sales of the FC Female Condom (14 million units). This will require a substantial increase in global demand. Three additional female condom products—the pro Woman’s Condom, the Silk Parasol Female Pantyasol Fo Condom, and the Belgian Female Condom—male Cone are in various stages of design, testing, and ign, testing, e regulatory approval. Regulatory approval of latory approval appro these products is contingent on the developers ent on the develothe receiving adequate funding for clinical trials and ng for clinical triaor clin regulatory applications. It will be several years cations. It will be several yl be seve before any of these new products hese new p ucts are available. The availability of more female condom productsy of more female condom promor cts will yield many beneﬁts for current and futureny beneﬁts for current and fneﬁ e users of the female condom. New products female condom. New prodmale co may improve acknowledged problems with themprove acknowledged problems knowled with the ﬁrst-generation product and therefore better generation product and thereforeoduct b meet users’ needs. Less-expensive design and et users’ needs. Less-expensive design and ess manufacturing and market competition maynufacturing and market competitioac rk result in lower product costs and thereforesult in lower product costs and the low greater access. The regulatory approval pathway eater access. The regulatory approval pathway acce these new products must follow is costly and ese new products must follow is coste new p difﬁcult, however, and can keep viable new ﬁcult, however, and can keep viacult, howe ble new products from reaching users. Amending theducts from reaching users. Amets from ing th clinical trial requirements and streamliningcal trial requirements and streamlireq the regulatory approval processes for female gulatory approval processes for femry condoms in the United States may help bringin the United States may help bring innovative products to market.ucts to market. Yes.s. Two new female condom models are in limited distribution, and o new female condom mw fe ondo a second-generation condom (FC2) will soon be available. Three newsecond-generation condom (Fnerat d products are in development but will not be available for several years.products are in development but will nd in d 24 Are there clear priorities for taking action now to increase access to and use of female condoms? 25 PRIORITIES Yes. The female condom is poised for greater use and impact. The greater use and impact The ter use need for effective disease protection is great, and female condoms have tection is great, and female condom have fem the potential to protect the health of millions of couples worldwide.the health of millions of couples worldwide The female condom is a key technology in the ﬁght against HIV/AIDS that awaits the full support of the global community. There are four key steps to be taken now to make the female condom more acceptable, accessible, and available. an 1. Develop greater political and social support for the female condom at local, national, and international levels. All stakeholders—donors, clients, service ll stakeholders—dokeholder providers, policymakers, researchers, and oviders, policymakers, researchers, and , po product developers—need to advocate for the duct developers—need to advocate for the fev female condom. Garnering and publicizing female condom. Garnering and publicizing g and publicin this support will contribute to greater publicthis support will contribute to greater pubte to gre awareness of, acceptance of, and demand for wareness of, acceptance of, and demance of, and d the female condom. female condo 2. Increase public- and private-sector investment in female condoms. Donors and governments need to increasents need to ﬁnancial and technical support for female condom programs as one of a number of cost- effective and necessary reproductive health investments. Public-sector program managers need assistance in developing innovative female condom programs that appropriately position and market the method within their communities. International agencies, governments, and manufacturers can facilitate price reductions through joint purchasing agreements. Governments can streamline the regulatory approval and procurement and supply process for new female condom products. The private and public sectors need to invest in the development and commercialization of new female condom products, as well as develop innovative channels for marketing and distributing existing products to speciﬁc audiences. 26 3. Scale up promotion of female condoms and monitor and evaluate impact. Increasing outreach, especially throughg partnerships with employers and community mm y and women’s groups, can increase thee demand for and supply of female condomsdoms and reach new users. Speciﬁc outreach andh and education efforts are needed to foster men’s acceptance of the female condom. Integrating female condom programming into existing reproductive health programs will increase the cost-effective distribution of the method, strengthen programs, and help make condoms part of mainstream reproductive health programming. With increased distribution and on an appropriate impact evaluation studies, it will it will w be possible to document the impact of femaleof femaleem condom programming on public health andea n justify continued program expansion. Greatero eater distribution and use ofdistribution and use of The Female Condom:Th F l C dale Con A Guide for Planning and Programmingde for Planning and Programming38 will be helpful in these efforts. Sharing informationful in these efforts.n aring information about successful female condom programs uccessful female condossfu ms and lessons learned, especially related tosons learned, especially related tolearne key elements such as developing effectivements such as devets such as condom negotiation skills and involving men, m negotiation skills ation sk will facilitate acceptance and diffusion of thetate acceptance accepta female condom.dom 4. Conduct research to improve programming. Rigorous studies that test ways to introduce and promote female condoms to speciﬁc audiences and evaluate the long-term impact of these efforts on public health can strengthen the case for the female condom. Operational research is needed to identify effective behavior change strategies, educate about risk, create demand for female condoms, and evaluate the impact of male involvement. “Male and female condoms should be Male and female cod fem readily available in all health care settings readily available inavailable … funding should substantially increase for … funding shouldnding s research into other prevention technologies, research into ot such as female condoms …”such as fem 47 — Global HIV Prevention Working Group, 2004 28 Universal access to prevention, treatment, and care for those affected by HIV/AIDS is a necessarye affected by HIV/AIDS is a necessary investment in the health of our communities. HIV prevention and treatment are interlinked, and the and treatment are interlinked, and hen only way to make treatment affordable and sustainable is to intensify prevention efforts. Women andintensify prevention efforts. Wo n ensify p men whose lives are at risk need access to a range of prevention options to make the choices thattion options to make the choi es thaoptions best ﬁt their circumstances. Given that the female condom effectively protects against pregnancy and fectively protects against pr nancy andy pro STIs and is the only female-initiated STI prevention method currently available, access to this method rently available, access to methoilable, is a public health right that needs to be ensured for all couples. 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Bulletin of the World Health Organization. 2004;82(6):454–461. US Centers for Disease Control and Prevention (CDC). Fact sheet for public health personnel: male latex condoms and sexually transmitted diseases. Atlanta, Georgia: CDC; 2004. Available at: www.cdc.gov/nchstp/od/latex.htm. Accessed April 27, 2006. Holtgrave D. Cost-effectiveness models prepared for the Female Health Company. Unpublished data, 2005. Marseille E, Kahn J, Billinghurst K, Saba J. Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa. Social Science and Medicine. 2001;52:135–148. Singh S, Darroch J, Vlassoff M, Nadeau J. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. Washington, DC: Alan Guttmacher Institute, UNFPA; 2003. Gutierrez JP, Johns B, Adam T et al. Achieving the WHO/ UNAIDS antiretroviral treatment 3 by 5 goal: what will it cost? The Lancet. 2004;364:63–64. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. Latka M. Female-initiated barrier methods for the prevention of STI/HIV: Where are we now? Where should we go? Journal of Urban Health. 2001;78(4):571–580. Simutami L. Strategies for purchase and supply of female condoms: PSI. Presented at: Global Consultation on the Female Condom, September 26-29, 2005; Baltimore, Maryland; and personal communication with L. Simutami, Population Services International, November 11, 2005. WHO, UNAIDS. The Female Condom: A Guide for Planning and Programming. Geneva: WHO, UNAIDS; 2000. Available at www .who.int/reproductivehealth/publications/RHR_00_8/index.html. Susser I, Stein Z. Culture, sexuality, and women’s agency in the prevention of HIV/AIDS in southern Africa. American Journal of Public Health. 2000;90(7):1042–1048. Kaler A. The future of female-controlled barrier methods for HIV prevention: female condoms and lessons learned. Culture, Health and Sexuality. 2004;6(6):501–516. Ministry of Health and Child Welfare Zimbabwe (MOHCW). Piloting the Female Condom in Zimbabwe: A National Survey. Harare, Zimbabwe: MOHCW; 1998. WHO. WHO Information Update: Considerations Regarding Reuse of the Female Condom. Geneva: WHO; 2002. Smith C. Female condom supply would save lives now. The Sunday Independent. November 27, 2005. Ahrens H. Sharing country experiences with the female condom: pe Brazil. Presented at: Global Consultation on the Female Condom,Cons September 26–29, 2005; Baltimore, Maryland.Baltimorti World YWCA. World YWCA calls for women’s equal access to YWCA calls foA prevention and treatment [press release]. Geneva: World WYCA; prevention and treatment [press releasnt [press r December 1, 2005. Available at: worldywca1.org/aids/wad_1, 2005. Available at: worldywable at: wDec statement.pdf. Accessed April 27, 2006.Accessed April 27, 2006.pril 27, 2statement.p PATH. The female condom: significant potential for STI and e condom: significant potential for andgnATH. The fem pregnancy prevention. pregnancy prevention. ven Outlook.tloo 2006;22(2):1–8.06;22(2):1–8. Global HIV Prevention Working Group. rking Gro HIV Prevention in the Era IV Prevention in the Evention of Expanded Treatment Accessof Expanded Treatment A . Global HIV Prevention Workingobal HIV Prevention Workingtion W Group; 2004. Available at: www.kff.org/hivaids/upload/HIV-Group; 2004. Available at: www.kff.org/hivaids/upload/HIV-s/uplp; 2004. Availab Prevention-in-the-Era-of-Expanded-Treatment-Access.pdf.vention-in-the-Era-of-Expanded-Treatment-Access.pd-in-the-Era-of- Accessed April 27, 2006.ed A l 27, 2006. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46.46 47. 30 Selected resources United Nations agencies The Global Coalition on Women and AIDS www.womenandaids.unaids.org The Joint United Nations Programme on HIV/AIDS www.unaids.org UNFPA www.unfpa.org World Health Organization www.who.int Program and research resourcesnd researr AVERT www.avert.orgt.o Brazil Ministry of Health, STD/AIDS Programistry of Health, STDof Hea www.aids.gov.brgo br DKT InternationalKT Internat l www.dktinternational.orgwww.dktinterna l.o EldisEl s www.eldis.orgwww.eldis.orgw. Family Health InternationalFamily Health Internationy He www.fhi.orgw hi.o The Global Consultation on the Female Condom he Global Consultation on the Female ConGlobal C (PDF ﬁles containing conference presentations)DF ﬁles containing conferences con www.path.org/projects/womans_condom_gcfc2005.phpw.path.org/projects/womanorg/ International Planned Parenthood FederationInternational Planned Parenthood Federation www.ippf.orgw.ipw KfW Development Bankvelopment BanKfW www.kfw.de.dww Marie Stopes Internationalpes Internationalarie S www.mariestopes.org.ukstopes.org.ukwww.m PATH www.path.orgwww.path.orgat Popline www.popline.org Population Council www.popcouncil.org Population Services International www.psi.org Reproductive Health and HIV Research Unit of the University of Witswatersrand, South Africa www.rhru.co.za Resources for Family Planning and HIV/AIDS Integration www.fpandhiv.org Reuse of the Female Condom www.reusefemalecondom.org UK Department for International Development www.dﬁd.gov.uk US Agency for International DevelopmentU www.usaid.gov 31 Manufacturers Female Health Company www.femalehealth.com Hindustan Latex Limited www.hindlates.com Medtech Health Products www.medtechproducst.org Natural Sensation Companyral Sensation Company www.natural-sensation.com.conatural-sensation.com.cow Silk Parasol Corporationasol CorporaSilk P www.silkparasol.comwww.silkparasol.co Other resources Center for Health and Gender EquityGend E it www.genderhealth.org Cervical Barriers Advancement Societyt www.cervicalbarriers.org Global Campaign for Microbicidesbal Campaign for MicrobicidesobCamp www.global-campaign.org/femalecondom.htmlww.global-campaign.org/femaleceobal-ca Implementing Best Practices in Reproductive Healthmplementing Best Practices ienting www.ibpinitiative.orgww.ibpinitiative.obpinitiativ Photo credits: COVER: PATH (Mike Wang), Richard Lord, China Youth Reproductive Health Project, PATH (Willow Gerber), Losevsky Pavel; PAGES 1 and 2: Richard Lord; PAGE 3: Photo courtesy of the David and Lucile Packard Foundation; PAGE 4: Female Health Company; PAGE 5: Reproductive Health and HIV Research Unit; PAGE 7: Dan Chang; PAGE 9: Richard Franco; PAGE 11: Photo courtesy of the David and Lucile Packard Foundation; PAGE 13: PATH (Mike Wang); PAGE 15: Richard Lord; PAGE 18: PATH (Mike Wang); PAGE 19: PATH (Willow Gerber); PAGE 22: PATH (David Jacobs); PAGE 23: Jianzhong Chen; PAGE 25: Richard Franco; PAGE 27: PATH (Jennifer Fox); PAGE 28: Richard Lord 32
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