What can be done to increase the use of condoms by men in African countries, to reduce HIV infection? The results of a study of six African countries with some of the highest HIV infection rates in the world show that measures need to be taken to boost the number of condoms on the market, improve government supply and increase access in rural areas and among poor people, among others.
PSI and the United Nations Population Fund (UNFPA) teamed up over the past year to study and report on the state of play in six African countries, including five located in the East and Southern Africa (ESA) region. The results were released in December 2013 following six new case studies that were presented at a consultative meeting on the Total Market Approach, hosted by PSI and UNFPA on 17-18 December.
During the meeting, participants discussed the findings from the case studies conducted in six African countries. Representatives from ten organizations then discussed how they could work together to support the development and implementation of the Total Market Approach in national markets for male condoms and other family planning supplies.
The UNFPA-sponsored case studies were carried out over 12 months with support from two independent researchers in Botswana, Lesotho, Mali, South Africa, Swaziland and Uganda. All of the countries have large condom social marketing programmes, are affected by HIV, and have high maternal morbidity and mortality relative to their economic development.
Content for the case studies was based on a review of the literature, seven key TMA metrics calculated from national-level data, and interviews with stakeholders. All case studies were subject to review by stakeholders, including Ministries of Health and non-governmental organizations, UNFPA’s local and regional offices, UNFPA headquarters in New York City, PSI country and regional offices, and PSI’s headquarters in Washington DC.
Each case study describes the market for male condoms in each of the countries, and the roles of the public, social marketing and commercial sectors in those markets. The cases illustrate the universe of need for condoms, levels of use, socioeconomic equity among users, and the market presence of condoms for reproductive health and HIV prevention (dual protection). They also propose a set of recommendations for improving the effectiveness, efficiency and sustainability of condom markets.
The studies aimed to inform the development of appropriate, evidence-based decisions to increase condom use equitably and sustainably through actions undertaken in the public, socially marketed and commercial sectors. This is what was found in the five ESA region countries:
Botswana
The prevalence of HIV in Botswana is among the highest in the world, with nearly one fifth of the population infected. Although large-scale HIV prevention efforts have resulted in a decrease in new infections over the past two decades, consistent condom use remains critical for preventing new infections.
The study found that:
- The number of condoms needed to protect people during all sexual acts from HIV infection and unplanned pregnancy (universe of need) is higher than the actual number of condoms on the market (volume).
- Inequity remains an issue and there is evidence to suggest that condom use is concentrated among wealthier segments of the population.
- Efforts should focus on those most in need, including the poor and those living in rural areas.
Lesotho
The prevalence of HIV in Lesotho is among the highest in the world, with almost one quarter of the adult population infected. Although large-scale HIV prevention efforts have resulted in a 16 per cent decrease in new infections, risky sexual behaviour and insufficient levels of condom use continue to drive the HIV epidemic.
Demand for condoms has increased over the years, including among those with higher risk behaviour. In 2012, 61 per cent of men and 46 per cent of women reported using a condom the last time they had sex, more than double the percentage in 2004 and more than 25 per cent higher than in 2009. Equity in condom use has also improved. According to recent data, approximately one third of condom users falls into the bottom two wealth quintiles.
The study found that:
- To meet increasing demand, all market sectors must address chronic shortages in supply, especially for free condoms.
South Africa
South Africa has the greatest number of people living with HIV in the world, with an estimated 16.9 per cemt of the adult population infected. Although large-scale HIV prevention efforts have resulted in a decrease in new infections, risky sexual behaviour and insufficient levels of condom use continue to drive the HIV epidemic.
The study found that:
- The number of condoms needed to protect people in all sexual acts from HIV and unplanned pregnancy (universe of need) is much higher than the actual number of condoms on the market (volume).
- Currently, lengthy condom procurement processes, an unreliable condom supply, and lack of government funds for warehousing and distribution cause inefficiencies in public sector distribution, which result in shortages throughout the country.
- Accessible, high quality data are needed to guide decisions by all market stakeholders.
Swaziland
Swaziland has the highest HIV prevalence of any country in the world, with more than one quarter of the adult population infected. Although large-scale HIV prevention efforts have resulted in a decline in incidence since 1998, risky sexual behaviour and insufficient condom use continue to drive the epidemic.
In 2012, approximately two thirds of men and women reported using a condom the last time they had sex, compared to fewer than half in 2006. Rates of condom use have also increased among unmarried youth, but are lower than rates in the general population.
Condom use is also no longer concentrated among the wealthy: nearly 40 per cent of condom users fell into the bottom two wealth quintiles in 2012, compared to less than 25 per cent in 2006.
The study found that:
- Limited coordination between the public sector and implementing partners, including non-governmental organizations (NGOs), results in an overstocking of free condoms in some locations while other sites are severely understocked.
Uganda
From 1992 to 2002, Uganda successfully reduced the prevalence of HIV/AIDS from 18 per cent to approximately 6 per cent; however, some concerning trends are emerging and HIV prevalence has increased, with an estimated 7.3 per cent of adults currently infected.
Condom use among the general population has increased, but overall demand still remains low, which helps explain why volumes are also low. Rates of use are higher among youth, but have decreased within some groups, including males with casual partners and females with multiple partners.
The study found that:
- The total market approach provides an opportunity for improved efficiency, equity, and sustainability in Uganda’s market for male condoms.
- Enhanced reporting systems could improve commodity projections and forecasting, which would help identify market needs as well as gaps in supply.
