Providing and promoting the female condom

Since 1999, more than 19 million female condoms have been supplied to 70 countries through an innovative public/private partnership brokered by UNAIDS in Africa, Asia and Latin America. The female condom is also promoted through the UN's programme addressing HIV/AIDS in the workplace.

A Global Female Condom initiative was launched by the United Nations Population Fund, UNFPA, in 2005, as the new-generation FC2 condom became available. This aims to scale up female condom programmes in more than 23 countries. UNFPA is helping national governments and other local stakeholders develop and implement their own strategies for integrating female condoms into reproductive health services. The UNFPA Initiative defines its aims as:

• Increasing the uptake of female condoms

• Empowering women to negotiate safer sex with partners

• Promoting the correct and consistent use of female condoms

• Advocating for the inclusion of female condoms in the WHO essential drug list.

The original female condom was relatively expensive. The Female Health Company (FHC) therefore developed the FC2, a cheaper nitrile rubber version of the polyurethane condom, and launched the product in October 2005.

In tests conducted at the Reproductive Health Research Unit in Durban, South Africa, women reported that there was no difference in performance between the old and new condoms and a third said they could not tell that they were different at all.

 “If countries in a region come together as a collective and place a large order [with FHC], this will allow the smallest country to get the best possible price,” she said.

Initially, the FHC only manufactured small numbers of the FC2 condom, but their strategy with this second-generation product was to concentrate initially on getting the product licensed in low- and middle-income countries, in accordance with the Global Female Condom Initiative, and then secure large distribution contracts with national governments and international funders.

The FHC only sought the approval of the FDA and of the European Patent Office after significant distribution to poorer countries had already been secured: the FC2 finally achieved FDA approval in October 2009¹ and European recognition a month later. The price of the FC2 in the USA was 30% lower than the FC1.

The current maximum price for public organisations is 82 US cents per unit, going down to 61 cents a unit for very large orders. The Female Health Company says this is a 30% reduction on the price of the PC1 condom (see www.fc2femalecondom.com/publicsectorbuying.html). Typical commercial retailers charge about $1.50 per unit (see, for instance, www.undercovercondoms.com/Condoms/Reality/3976/Female-Condom-FC2.html).

The FC2 received registration by the Indian authorities in September 2006, and the FHC secured a manufacturing contract with the company Hindustan Latex Ltd. By April 2009 FHC and HLL had secured orders of 1.5 million FC2 condoms by the Indian National AIDS Control Organisation.

An even larger order had been secured in October 2008, when 4.3 million FC2s were ordered by the joint Australian/Papua New Guinea HIV and AIDS programme, intended mainly for Papua New Guinea, which accounts for 70% of all HIV infections in Australasia.

The New York City Department of Health distributed 900,000 FC1 female condoms in 2008, and in November 2009 sponsored an education seminar for 200 health educators to introduce the FC2. Other US health departments have followed suit in trying to increase awareness and uptake of the FC2. In March 2010, a coalition of 20 non-profit HIV and women’s advocacy organisations in Chicago launched an awareness campaign including a website – www.ringonit.org – to increase local uptake. And in Washington, DC, a campaign to promote the FC2 featured posters on a third of the city’s buses. This city was also the first to allow over-the-counter sales of the FC2.

The US city campaigns featured African HIV prevention advocates and co-ordinators travelling from countries such as Malawi to educate American providers in its promotion and use. Sandra Mepemba of the UN Population Fund (UNFPA), who recently led Malawi’s national transition from the FC1 to the FC2 condoms, told her New York audience: “The evidence is clear that when women and men have access to the female condom and education on its use, it becomes a product they demand.”

One of the biggest barriers to the large-scale adoption of the female condom has been cost. The original Female Health Company polyurethane condom was made available to donor programmes via an agreement with UNAIDS at a unit cost of US$0.72, which is 24 times the cost of the male condom ($0.03). When the additional cost of the kind of comprehensive HIV and STI programme that is necessary in order to successfully increase condom use is taken into account – a programme which would involve training, advocacy, promotion, marketing, distribution and monitoring – the cost inequality is slightly reduced, but even at this ‘fully loaded’ cost, each first-generation female condom was still 12 times as expensive as each male one ($1.28 versus $0.11).

However, while the price of male condoms appears to have reached a minimum, the price of the female condom is continuing to decrease, reflecting wider uptake and the resulting efficiencies of scale. The current ‘fully loaded’ cost has decreased by 60% since 2000, when it was calculated as $2.96 per unit, and will decrease further if more are sold.

At present, the female condom is too rarely used for it to have a measurable public-health impact in terms of pregnancy, HIV and STI figures in any one country or large population. It is therefore not possible to arrive at empirical, post-hoc figures for its cost-effectiveness in reducing morbidity, mortality and unwanted pregnancy. However, mathematical modelling suggests that it would be cost-effective if it became a widespread method of HIV prevention. For example, the Female Health Company has calculated that in South Africa, if four million female condoms were distributed at the cheaper but achievable price of $0.77 per unit, this would prevent 1740 HIV infections - resulting in a net saving to the healthcare system of $980,000.² Another kind of model calculated that spending $4000 on female condoms for commercial sex workers in the same country would result in a net saving of $9000 to the healthcare sector.

Examples of countries where female condoms have been promoted successfully include Brazil, India, Papua New Guinea, South Africa and Zimbabwe.

In Brazil, the female condom was first socially marketed by the private-sector company DKT do Brasil in 1997. Following a large-scale acceptability study in 1999, the government then started free or low-cost provision of female condoms, targeting sex workers, women with HIV and/or STIs, female drug users and women at risk of violence. In 2000/01, almost two million female condoms were distributed in the country and by 2003/4 this figure had doubled to four million, reflecting a successful programme of outreach and of training service providers in how to introduce and demonstrate the proper use of the female condom. The Brazilian government estimates that the four million distributed represent about one-fifth of the number actually needed by the targeted women.

In South Africa, eight out of the country’s nine provinces introduced a pilot programme in 1998, targeting female-condom distribution to family planning clinics and via outreach to commercial sex establishments and sex-worker sites. There was also a social marketing campaign. In 2004, 1.4 million female condoms were distributed through the government programme. Research has shown that most female-condom recipients were in their 20s and were already using oral contraceptives.

In Zimbabwe, women’s groups collected more than 30,000 signatures from women demanding access to the female condom, resulting in the government deciding to import it. It is now marketed successfully to couples as the Care Contraceptive Sheath.

The contrast in the way the condom is promoted in adjacent African countries shows how varied attitudes can be and how national and cultural attitudes towards women and sex need to be taken into consideration. South African women and couples were quite happy to use the female condom when it was promoted as an HIV preventative measure, but in Zimbabwe research showed that the stigma of HIV and behaviours associated with it were so great that promoting the female condom as a contraceptive resulted in better acceptance.