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LETTER |
The author is with the Center for Studies of Addiction, University of Pennsylvania, Philadelphia.
Correspondence: Requests for reprints should be sent to Erica Gollub, DrPH, Treatment Research Center–Bldg 4, 3900 Chestnut St, Philadelphia, PA 19104 (e-mail: gollub_e{at}research.trc.upenn.edu).
The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have printed an 80-page program and planning guide for the female condom that has been distributed in more than a dozen countries,1 as well as a 40-page summary of 42 studies of female condom acceptability.2 WHO/UNAIDS has funded large effectiveness trials3 and many field projects dedicated to optimal introduction of this method. From 1997 to 2001, 12.9 million female condoms were purchased for global use under a UNAIDS–Female Health Company partnership (personal communication; M. Warren, The Female Health Company; June 2001). In late May, UNAIDS executive director Peter Piot stated that "both male and female condoms need to be more readily available ... to increase the options for women to protect themselves—and increasing means from zero to one."4
In contrast, the 1993 and 1998 publications Green cites give cursory treatment—only 8 to 9 lines—to the female condom, mentioning neither the consistently positive behavioral data nor the data showing that the device tears less easily than a male condom.5 In these advisories, instead, between 22 and 44 lines are dedicated to the male condom, with user tips, information on breakage and slippage, and recommendations for carriage and storage. No Centers for Disease Control and Prevention (CDC) updates have been issued since 1998 regarding the more than 20 US published studies of the female condom or the contraceptive study data indicating 6-month female condom failure rates as low as 0.8% to 3.2%.6,7,8 No technical assistance is routinely offered by CDC to health departments to integrate the female condom into HIV counseling and testing programs. No partnership activities exist with the manufacturer. A CDC head has yet to publicly endorse the female condom as an important infection-fighting tool.
Green states that in a recent study at a sexually transmitted disease clinic, few women consistently used the female condom. If "consistent use" were the criterion to measure a method's contribution to HIV prevention efforts, the male condom—now, after vigorous promotion for 15 years—would fail. In high-risk groups, only 4% to 17% report consistent use,9 and in national surveys, the figure rises to no more than 33%.10
But such a standard undermines our immediate goal of risk reduction—the appropriate response to the public health emergency of HIV in women. Overlooked by Green in the STD clinic study she cites is that the proportion of protected acts increased substantially with the introduction of the female condom, from less than 40% to nearly 70%.11,12 The latter result was found in other studies, too—from double to triple the baseline rate of protection.13,14
In the view of many of us, a major CDC investment in training health workers to introduce and promote the female condom would signal a desperately needed change from indifference or skepticism to proactive support and would have a real and lasting impact on public health.
References
1. The Female Condom: A Guide for Planning and Programming. Geneva, Switzerland: WHO/UNAIDS; 2000.
2. The Female Condom. Geneva, Switzerland: UNDP/UNFPA/WHO/World Bank Special Program on Research, Development and Research Training in Human Reproduction; 1997.
3. Fontanet AL, Saba J, Chandelying V, et al. Increased protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: a randomized controlled trial. AIDS.1998;12:1851–1959.[Medline]
4. In the war on AIDS, a UN official accents prevention. New York Times. May 28, 2001:XX.
5. Drew WL, Blair M, Miner RC, Conant M. Evaluation of the virus permeability of a new condom for women. Sex Transm Dis.1990;17:110–112.[Medline]
6. Trussell J, Sturgen K, Strickler J. Contraceptive efficacy of the female condom and other barrier methods. Fam Plann Perspect.1994;26:66–72.[Medline]
7. Cecil H, Perry MJ, Seal DW, Pinkerton SD. The female condom: what we've learned thus far. AIDS Behav.1998;2:241–256.
8.
Gollub E. The female condom: empowerment tool for women. Am J Public Health.2000;90:1377–1381.
9. Soler H, Quadagno D, Sly DF, Riehman KS, Eberstein IW, Harrison DF. Relationship dynamics, ethnicity and condom use among low-income women. Fam Plann Perspect.2000;32:82–88, 101.[Medline]
10. Cornelius LJ, Okundaye JN, Manning MC. Human immunodeficiency virus-related risk behavior among African American females. JAMA.2000;92:183–195.
11.
Artz L, Macaluso M, Brill I, et al. Effectiveness of an intervention promoting the female condom to patients at sexually transmitted disease clinics. Am J Public Health.2000;90:237–244.
12. Macaluso M, Demand M, Artz L, et al. Female condom use among women at high risk of sexually transmitted disease. Fam Plann Perspect.2000;32:138–144.[Medline]
13. Musabe E, Morrison CS, Sunkutu MR, Won EL. Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia. Sex Transm Dis.1998;25:1–5.[Medline]
14. Latka M, Gollub E, French P, Stein Z. Male and female condom use among women after counseling in a risk reduction hierarchy for STD prevention: results from an STD clinic sample. Sex Transm Dis.2000;27:431–437.[Medline]
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