Comprehensive HIV Prevention: Condoms and Contraceptives Count

This Population Action International (PAI) report presents evidence that scaling up HIV prevention will require much broader access to and use of proven prevention technologies - "namely male and female condoms to prevent primary infection, and contraceptives to prevent mother-to-child transmission by preventing unintended pregnancies". The report details public health strategies and a programming framework that can be applied to address gaps in the provision and use of condoms and contraceptives.

The report focuses on prevention because in 2007, new HIV infections outnumbered persons receiving treatment by nearly 3 to 1. The authors state that "behavior change, including condom use, is critical to stemming the number of new infections... High rates of unintended pregnancies, including among women living with HIV or AIDS, is an urgent health and rights crisis. Preventing unintended pregnancies among women living with HIV and AIDS and those at risk of infection is essential for preventing mother-to-child transmission of HIV....Persistent variations in condom use across regions, countries and populations indicate that condom promotion should be targeted to address socio-cultural, political, economic and structural barriers faced by different groups (e.g. youth, married women and men, discordant couples, sex workers, men who have sex with men, and injecting drug users, among other groups).... Despite 2.5 million new HIV infections occurring every year, overall donor support for condoms in developing countries has remained largely unchanged over the past few years. Similarly, despite a growing demand for modern contraception, including condoms, donor support for contraceptives has increased only minimally, and remains far below the projected need."

Key recommendations include:

1. Use the more than 20 years of epidemiological, psychological, programming, and marketing data to design a comprehensive prevention strategy that supports national and local ownership and generates local solutions to affecting the social and gender norms that influence sexual behaviour and use of condoms and contraceptives, among other prevention strategies.
   
2. Close the gap in funding between prevention and treatment. Increasing funding for condom availability is a primary strategy for scaling up programmes.
   
3. Eliminate harmful government policies - the authors cite needs for "strong leadership and coordination - for advocacy and policy dialogue....Scale up also requires a supportive policy environment - one where policies are based on sound evidence that supports the efficacy of condoms and contraceptives in prevention the transmission of HIV. Likewise, the integration of contraceptives into HIV prevention programs must be supported at all policy levels."
   
4. Scale up and integrate condoms and contraceptives into other HIV prevention strategies, based on the social marketing concept of supply, demand, and support, and built on a foundation of leadership and coordination. The Comprehensive Condom Programming (CCP) Framework (scroll down to Box 10) is introduced in the report.
5. Logistics are fundamental to making sure condoms and contraceptives get where they are needed most to avoid stock-outs and ensure a range of available methods. "Regarding female condoms, there is a need for attention to their introduction and marketing, as well as mechanisms to coordinate and track commodity procurement and distribution for both male and female condoms." Condom forecasts must be made well in advance of when the condoms will actually be used. Mechanisms "such as the RH Supplies Coalition, global logistics support projects, and tools such as the RHInterchange (scroll down to Box 11) can help with commodity management and should be expanded."
6. Put the contraceptives in comprehensive prevention to address high rates of unintended pregnancies, through expanding voluntary family planning services integrating family planning with other HIV services to increase contraceptive use.
   

Regarding costs, the report suggests that distributing condoms and contraceptives across a range of networks can help to reduce costs of service delivery and promotion by maximising the contribution of existing outlets and programmes. By limiting subsidised or free condoms to low-income consumers, market segmentation maximises government and donor investments, freeing up funds for other strategies.