Promoting Female Condom Use Among Female University Students in KwaZulu-Natal, South Africa: Results of a Randomized Behavioral Trial.

Relatively few interventions have tested the efficacy of female condom promotion either alone or in combination with other barrier methods. We evaluated the efficacy of a two-session (enhanced) cognitive-behavioral intervention (EI) (n = 147) against a one-session control (minimal) educational intervention (MI) (n = 149) to promote female condom (FC) use among female students aged 18-28 at a South African university. We assessed change from baseline to 2.5 and 5 months in number of vaginal intercourse occasions unprotected by male or female condoms in EI versus MI using generalized linear models with a log link function and GEE. Both groups reported significant reductions in number of unprotected vaginal intercourse occasions from baseline to each follow-up, with no significant difference between the two-session and single-session intervention. Introduction of a brief group-based MI FC promotion intervention with FC access holds promise for delivery in clinics and other community venues.

Failure to test children of HIV-infected mothers in South Africa: implications for HIV testing strategies for preschool children.

OBJECTIVES: To assess the uptake of HIV testing among preschool children with HIV-positive mothers in a peri-urban population-based study in KwaZulu-Natal, South Africa, an area of high HIV prevalence. METHODS: All children 4-6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty-seven HIV-infected mothers were interviewed to identify barriers to testing their children. RESULTS: One thousand five hundred and eighty-three children (88% of eligible children) and their caregivers participated. Of the biological mothers, 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother, only 41% had been tested for HIV (23% tested positive). Subsequently, 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV-infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. CONCLUSIONS: In this community with high HIV prevalence, HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV, particularly those of infected mothers, is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children, especially for those who missed PMTCT opportunities in infancy.

Off-label use of the female condom for anal intercourse among men in New York City.

We surveyed 111 male clients of an HIV/AIDS service organization in New York City in 2008 and 2009. Seventeen percent had used the female condom for anal intercourse; of these, 89.3% had used the female condom with male partners, 21.4% with female partners, and 10.7% with both. Users of the female condom for vaginal intercourse were more likely to use it for anal intercourse (odds ratio = 12.7; 95% confidence interval = 2.5, 64.9; P = .002). The safety and efficacy of the female condom for anal intercourse are unknown and should be evaluated.

Project REACH: a provider-delivered dual protection intervention for women using family planning services in New York City.

High rates of unintended pregnancies and sexually transmitted infection (STI), including HIV, highlight the importance of promoting dual protection (DP) - i.e., methods that offer concurrent protection against unintended pregnancies and STI - during contraceptive counseling. Using a Phase II quasi-experimental design, this study compared an individualized, clinic-based, nurse-delivered intervention designed to increase DP against standard of care among 101 HIV negative women accessing contraceptive services in medically under-served areas of New York City. Participants were evaluated at baseline, post-counseling, and six months later. Findings indicated that the intervention has possible benefit. At six-month follow-up, there was greater perceived susceptibility to STI and fewer condom-unprotected vaginal sex occasions in the intervention arm. Women in the intervention also had five times the odds of reporting female condom use. Results suggest that this intervention has the potential for a larger population impact and should be more rigorously evaluated in a Phase III trial.

Everywhere you go, everyone is saying condom, condom. But are they being used consistently? Reflections of South African male students about male and female condom use.

Young men in South Africa can play a critical role in preventing new human immunodeficiency virus (HIV) infections, yet are seldom targeted for HIV prevention. While reported condom use at last sex has increased considerably among young people, consistent condom use remains a challenge. In this study, 74 male higher education students gave their perspectives on male and female condoms in 10 focus group discussions. All believed that condoms should be used when wanting to prevent conception and protect against HIV, although many indicated that consistent condom use was seldom attained, if at all. Three possible situations for not using condoms were noted: (i) when sex happens in the heat of the moment and condoms are unavailable, (ii) when sexual partnerships have matured and (iii) when female partners implicitly accept unprotected sex. Men viewed it as their responsibility to have male condoms available, but attitudes about whose decision it was to initiate condom use were mixed. Almost all sexually active men had male condom experience; however, very few had used female condoms. Prevention initiatives should challenge traditional gendered norms that underpin poor condom uptake and continued use and build on the apparent shifts in these norms that are allowing women greater sexual agency.

Adding the female condom to the public health agenda on prevention of HIV and other sexually transmitted infections among men and women during anal intercourse.

Legal barriers to conducting public health research on methods of protection for anal intercourse were lifted in the United States in 2003 when the US Supreme Court invalidated all state antisodomy laws. Although research funding has been available for the development of rectal microbicides, the female condom, which has already been approved for vaginal use, has not been evaluated for anal use. Although there is no evidence that the female condom is safe for anal intercourse, it has already been taken up for off-label use by some men who have sex with men. This demonstrates the urgent need for more protection options for anal intercourse and, more immediately, the need to evaluate the safety and efficacy of the female condom for anal intercourse.

Anal use of the female condom: does uncertainty justify provider inaction?

Despite limited safety data and the absence of efficacy data, several studies have reported that the female condom is being used for anal sex by men who have sex with men. We describe providers' awareness of female condom use during anal sex among their clients and their experiences in counseling clients. We conducted semi-structured interviews with 78 health-care providers recruited from various health-care delivery systems in New York City: a family planning agency, a sexually transmitted infection agency, a hospital-based obstetrics and gynecology clinic, and two community-based AIDS service organizations. While two-thirds of providers reported that they were uncertain as to whether the female condom could or should be used for anal intercourse, nearly one-third believed that anything is better than nothing to prevent HIV/sexually transmitted infections during anal sex. Few providers had actually talked with clients about anal use of the female condom, and clients themselves had seldom mentioned nor asked for information about such use. Our findings highlight providers' uncertainty about anal use of the female condom. Lacking guidelines regarding the safety and efficacy of female condom use during anal sex, health-care providers are left to make their own well-intentioned recommendations (or not) to potential users. The dearth of information on female condom use during anal sex could encourage individuals to use the female condom for anal sex, which may increase HIV transmission risk or represent a missed opportunity for protecting non-condom users. There is a need for a series of harm-reduction, acceptability, and efficacy studies and, in the interim, for the development of a carefully qualified safety set of guidelines regarding anal use of the female condom for health-care providers.

Breast feeding: A time to craft new policies.

New studies of breastfeeding have discovered or confirmed the benefits to mother and child. They reinforce an emphasis on exclusive breastfeeding - no other food or fluids - during the first 6 months. Studies include findings from across the world, in well-resourced and poorly resourced settings. They also emphasize longer duration of breastfeeding, into the second year of life, and gradual rather than abrupt weaning. For HIV-infected mothers, the dangers of non-exclusive feeding in the first half year of life have been well documented in recent publications. Other studies open up the possibilities for antiretroviral treatment to accompany breastfeeding, whether given to the mother, or child, or both. To be effective, implementation of any recommendations must consider individual, family, and community resources.

Gender norms in South Africa: implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution.

In post-Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for women's ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively 'privileged' group, there is little information on gender norms that might shape responses to HIV-prevention programmes. To elicit gender norms regarding women's and men's roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi-structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV- and pregnancy-prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of women's rights in the post-Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co-existence of traditional constructions of gender that operate to constrain women's freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote women's protection against unintended pregnancy and HIV/STIs.

Women in the time of AIDS: barriers, bargains, and benefits.

We comment here on the implications of new HIV prevention technologies (physical and chemical barriers) for women's health and women's rights. Four relevant themes are selected that have emerged in the social and behavioral science literature: structural factors (global and national) limiting the availability of female condoms, control and empowerment with female-initiated HIV prevention technologies, covert use of female-initiated HIV prevention technologies, and male partners as part of the bargain for barriers. There is now a rich and diverse literature on all of these issues, relevant and informative (much is addressed in this issue), which we draw together in this commentary. Discussion of these themes suggests guidelines for policy, research, and action. First, the misconceptions, biases, and prejudices of global and national leaders, including donors, necessitate that we persevere in presenting data to them and engaging them in discussion. Second, we need to support women within their local social contexts to negotiate for their rights, balancing pragmatic approaches to their partners in their initiation of protection, and applying according to each situation as appropriate, a continuum from discretion and clandestine use to deception. Third, men have to be brought in as active participants, and their positive and negative experiences and interests inserted into practices and policies.

Notes on the female condom: experiences in Brazil.

A nationwide effort to introduce the female condom (FC) into public health services was undertaken in Brazil in 1998-99. To this end, the Ministry of Health sponsored a national research group of public health professionals, aided by local field workers and supervisors, to conduct a preparatory study at 20 sites in six cities. Clinic health workers were trained to conduct the study. Following an educational session, 2382 women volunteered to use the FC and to report their experiences at follow-up. Among those seen at 15 days, 1782 had used the FC at least once; among those seen at the 90-day follow-up, 1453 women had used it at least once, while 1296 of them liked it and wished to continue its use. Among these 1296 women, barrier use at last intercourse (either with a male or a female condom) was more than double at 90 days what it had been at baseline: 70% compared with 33%. Clinics providing active health-education activities achieved higher rates of follow-up and of FC acceptability. These findings suggest that in Brazil, the introduction of the FC at public health centres could lead to high initial adoption rates and that continued use would be effective in encouraging safer sex. The level of health education and type of clinic are likely to influence the effectiveness of a future programme.

The Mpondombili Project: preventing HIV/AIDS and unintended pregnancy among rural South African school-going adolescents.

Unintended pregnancy, HIV and other sexually transmitted infections are major threats to the health of South African youth. Gendered social norms make it difficult for young women to negotiate safer sex, and sexual coercion and violence are prevalent. Sexual activity among adolescents is influenced strongly by conservative social norms, which favour abstinence. In reality, most young people are sexually active by the end of the teen years. Girls' decision to have sex is often a passive one, influenced by partners. The Mpondombili Project is a school-based intervention in rural KwaZulu-Natal that aims to promote delay in the onset of sexual activity and condom use as complementary strategies for both sexually experienced and inexperienced youth. Interactive training was carried out with peer educators, teachers and nurses over a 15-month period, and a manual developed. The intervention was implemented in late 2003 with 670 adolescents in two schools. Issues covered included HIV/STI transmission, risk behaviours, HIV testing, pregnancy and contraception, gender inequality, sexual communication and negotiation, managing abusive situations, fear of AIDS, stigma and discrimination and sexual rights. The diversity of young people's relationships and vulnerability to sexual risk call for the promotion of both risk avoidance (delay in sexual initiation) and risk reduction (condom use) together, regardless of ideology, especially where HIV is well-established, to protect their health.

Gender-Focused HIV and Pregnancy Prevention for School-Going Adolescents: The Mpondombili Pilot Intervention in KwaZulu-Natal, South Africa.

This pilot study evaluated a 15 session classroom intervention for HIV and pregnancy prevention among grade 8-10 boys and girls (ages 14-17) in rural South Africa, guided by gender-empowerment theory and implemented by teachers, nurses, and youth peer educators. Pre- and post-intervention surveys included 933 male and female students in two intervention and two comparison schools. MAIN OUTCOME: condom use at last sex; secondary outcomes: partner communication; gender beliefs and values; perceived peer behaviors; self-efficacy for safer sex. At five months post-intervention, change in condom use did not differ between intervention and comparison schools. Intervention school youth had greater increases in self-efficacy for unsafe sex refusal [OR=1.61; 95% CI=1.01, 2.57] and condom use [OR=1.76; 95% CI=1.07, 2.89], partner communication [OR=2.42; 95% CI=1.27, 4.23], and knowledge of HIV testing opportunities [OR=1.76; 95% CI=1.08, 2.87]. This gender-focused pilot intervention increased adolescents' self-efficacy and partner communication, and has potential to improve preventive behaviors.