A crossover comparison of two types of female condom

A qualitative study on the clinical safety and user experiences of female condoms for anal intercourse among men who have sex with men in Shanghai, China

Objective

This qualitative study aimed to understand the clinical safety, efficacy, and receptiveness of using the female condom (FC) during anal intercourse among men who have sex with men (MSM).

Methods

Subjects for this study were recruited from a two-group crossover trial among MSM in Shanghai. The trial consisted of two phases, each including the use of condoms (FC vs. male condom), questionnaires, and in-depth one-on-one interviews. The two phases were separated by a washout period of 4 weeks. The minimum sample size for this study was determined in accordance with the principle of "information saturation." The qualitative data were organized and analyzed using ATLAS.ti version 7.

Results

A total of 26 participants from the MSM population were recruited for this study, with 10 assuming the insertive role (i.e., "1"), 8 assuming the receptive role (i.e., "0"), and 8 being versatile (i.e., "0.5"). Each participant completed the crossover trial comprising two phases. The cumulative usage of FCs and male condoms (MCs) amounted to 115 and 127 times, respectively. During the reported sexual encounters, no participants reported incidents of condom rupture, slippage, or other malfunctions. A few participants reported experiencing slight chafing pain, primarily put forward by "0" participants. Apart from those reports, no instances of bleeding, swelling, or allergic reactions were reported. The efficiency of FC in disease prevention, the sexual partner's willingness to use FC, the freshness of FC, and positive sexual experiences were the main reasons for the consistent use of FC for anal sex. Discomfort and pain during sexual activity, the loose design and thick material of FCs, and difficulties in placing FCs were the major obstacles to FC use among MSM. The elements referring to the forehead exhibited varied in importance among "1,", "0," and "0.5" participants. Regarding the willingness to use the FC in the future anal intercourse, 61.54% of participants expressed a positive inclination, 23.08% were uncertain, and 15.38% stated that they would not. "A better sense of security during anal sex" was the main factor affecting willingness among "0" participants and "the sexual pleasure that the FC brought" among "1" participants. Improving the design and technology of FCs and increasing the frequency of use and practice might improve the use skills, which will favor the willingness to use FCs among the MSM population.

Conclusion

FCs received positive user feedback from study participants, but distinctions were found in individuals in different sexual roles. Large-scale quantitative studies are needed to evaluate the clinical safety of the FC and its effectiveness in preventing the transmission of STDs during anal intercourse.

A systematic review exploring the contraception values and preferences of sex workers, transmasculine individuals, people who inject drugs, and those living in humanitarian contexts

Objective

We sought to systematically review the literature on values and preferences regarding contraception among individuals within selected key populations.

Study design

As part of a larger set of reviews on patients’ and providers’ values and preferences related to contraception globally, we searched ten electronic databases for articles from January 1, 2005 to July 27, 2020. No language restrictions were applied. Data was independently abstracted by two authors and study rigor was assessed using an 8-item measure developed by the Evidence Project for quantitative studies and an adapted CASP checklist for qualitative studies.

Results

We identified 12 studies that met our inclusion criteria examining selected key populations, including sex workers, transmasculine individuals, people who inject drugs, or those living in humanitarian contexts. Seven key themes that spoke to values and preferences emerged related to: autonomy, perceived effectiveness and safety, birth spacing and family outcomes, impacts on sexual experience, hormonal effects (e.g. desire for non-hormonal method or perception that the method is more natural as compared to hormonal methods), physical attributes (e.g. appearance and/or ease of use), and stigma. Six studies were of high rigor, five were of moderate rigor, and one was of low rigor. One study described the values and preferences of two of the selected key populations. The research available on the values and preferences of sex workers regarding methods of contraception was limited to female condoms.

Conclusion

Consideration of the values and preferences of individuals within selected key populations can inform providers, programme managers and policy makers participating in the delivery of contraceptive care. Contraceptive research among sex workers, transmasculine individuals, people who inject drugs, or those living in humanitarian contexts is quite limited; further research is needed to better understand the values and preferences of these populations.

Effectiveness of the female condom in preventing HIV and sexually transmitted infections: a systematic review and meta-analysis

BACKGROUND

The effectiveness of female condoms for preventing HIV and sexually transmitted infections (STIs) remains inconclusive. We examined the effects of female condoms on the acquisition of HIV and STIs.

METHODS

We searched four databases, two trial registries, and reference lists of relevant publications in October 2018 and updated our search in February 2020. We screened search output, evaluated study eligibility, and extracted data in duplicate; resolving differences through discussion. We calculated the effective sample size of cluster randomised trials using an intra-cluster correlation coefficient of 0·03. Data from similar studies were combined in a meta-analysis. We performed a non-inferiority analysis of new condoms relative to marketed ones using a non-inferiority margin of 3%. We assessed the certainty of evidence using GRADE.

RESULTS

We included fifteen studies of 6921 women. We found that polyurethane female condoms (FC1) plus male condoms may be as effective as male condoms only in reducing HIV acquisition (1 trial, n = 149 women, RR 0.07, 95%CI 0.00-1.38; low-certainty evidence). However, the use of FC1 plus male condoms is superior to male condoms alone in reducing the acquisition of gonorrhoea (2 trials, n = 790, RR 0.59, 95%CI 0.41-0.86; high-certainty evidence) and chlamydia (2 trials, n = 790, RR 0.67, 95%CI 0.47-0.94; high-certainty evidence). Adverse events and failure rates of FC1 were very low and decreased during follow up. Although the functionality of newer female condoms (Woman's, Cupid, Pheonurse, Velvet, and Reddy) may be non-inferior to FC2, there were no available studies assessing their efficacy in preventing HIV and STIs.

CONCLUSION

The use of female plus male condoms is more effective than use of male condoms only in preventing STIs and may be as effective as the male condom only in preventing HIV. There is a need for well conducted studies assessing the effects of newer female condoms on HIV and STIs.

PROSPERO REGISTRATION NUMBER

CRD42018090710.

Short-term acceptability of the Woman's Condom and influencing factors among internal migrants in China

Background

The Woman’s Condom, a newly designed condom for women, has obtained market approval in China, but it remains relatively unfamiliar to the migrant population. The aim of this study is to evaluate the short-term acceptability of the Woman’s Condom and influencing factors among internal migrants.

Methods

A longitudinal study was conducted among 1800 migrants in Beijing, Chongqing, and Shanghai in China between August 2013 and August 2014.Three-level model was implemented with the Statistical Analysis System software (v.9.4 SAS Institute) to analyze within-individual changes, between-individuals effects, and between-group effects.

Results

Three-level model analysis revealed statistically higher short-term acceptability of the Woman’s Condom among subjects who lived in Shanghai (β = 6.50, t = 2.76, p < 0.01), unmarried and not in a cohabiting relationship (β = 3.05, t = 2.76, p < 0.01) than those who lived in Beijing, married and in a cohabiting relationship. Female (β = − 1.69, t = − 7.55, p < 0.01) and lower educational attainment (β = − 2.30, t = − 1.94, p = 0.05) were negatively related, while occupations of education, health, and civil staff (β = 1.50, t = 2.92, p < 0.01) were positively related to acceptability. It was predicted that migrants’ acceptability of the Woman’s Condom would significantly increase over time (β = 1.09, t = 5.54, p < 0.01).

Conclusions

The findings indicate that the Woman’s Condom enjoyed relatively high short-term acceptability among migrants in China. In order to popularize the Women’s Condoms in migrants, more publicity, consultation and training in open and prosperous areas should be strengthened.

Indigenous HIV Prevention Beliefs and Practices Among Low-Earning Chinese Sex Workers as Context for Introducing Female Condoms and Other Novel Prevention Options

New interventions to reduce HIV and sexually transmitted infections (STI) among female sex workers are introduced into the context of women's existing prevention beliefs and practices. These indigenous practices affected implementation of our program to introduce female condoms to women in sex-work establishments in southern China. We used ethnographic field observations and in-depth interviews to document common prevention methods women reported using to protect themselves before and during intervention implementation. Individual, sex-work establishment, and other contextual factors, including sources of information and social and economic pressures to use or reject prevention options, shaped their perceptions and selection of these methods and affected adoption of female condoms as an additional tool. Efforts to improve uptake of effective prevention methods among low-income sex workers require attention to the context and spectrum of women's HIV/STI prevention practices when introducing innovations such as female condoms, microbicides, pre-exposure prophylaxis pills, and others, as they become available.

The constraints and concerns regarding the size and/or shape of the second generation female condom: The narratives from the healthcare providers

Background

Despite the redesigning of the Reality condom (FC) to a new version of the second generation female condom commonly known as (FC2), the users are persistently constrained and concerned about the size and shape of this new version. Condom use is aligned to the Millennium Development Goals (MDG) 3, 5 and 6, which address gender equality, improving maternal health and preventing HIV and AIDS.

Aim

To explore and describe the constraints and concerns regarding the size and/or shape of the FC2.

Setting

The study was conducted at Tshwane health district in Gauteng province.

Methods

A qualitative exploratory descriptive design was used. Individual in-depth interviews that yielded narratives in a designated health district in South Africa were conducted.

Results

From the analysis of narratives three specific themes emerged. Firstly, the specific theme was that the size and shape of FC2 is undesirable for the health care providers, which may lead women to contract HIV and AIDS. The second theme was that the size and shape of FC2 and female genitals makes insertion complicated and predisposes women to be vulnerable in sexual relationships. The third was that the size and shape of FC2 results in pain and discomfort during coitus, exposing women to unwanted pregnancies and HIV and AIDS.

Conclusions

The findings indicated the need for an evocative collaborative, interdisciplinary ‘walk the talk’ sexual health and AIDS education training programme for health care providers in primary health care facilities. Such programmes, if maintained, may assist health care providers to achieve the MDG 3, 5 and 6.

Knowledge, attitudes, practices and behaviors associated with female condoms in developing countries: a scoping review

Women in developing countries are at high risk of HIV, sexually transmitted infections, and unplanned pregnancy. The female condom (FC) is an effective dual protective method regarded as a tool for woman’s empowerment, yet supply and uptake are limited. Numerous individual, socioeconomic, and cultural factors influence uptake of new contraceptive methods. We reviewed studies of FC knowledge, attitudes, practices, and behaviors across developing countries, as well as available country-level survey data, in order to identify overarching trends and themes. High acceptability was documented in studies conducted in diverse settings among male and female FC users, with FCs frequently compared favorably to male condoms. Furthermore, FC introduction has been shown to increase the proportion of “protected” sex acts in study populations, by offering couples additional choice. However, available national survey data showed low uptake with no strong association with method awareness, as well as inconsistent patterns of use between countries. We identified a large number of method attributes and contextual factors influencing FC use/nonuse, most of which were perceived both positively and negatively by different groups and between settings. Male partner objection was the most pervasive factor preventing initial and continued use. Importantly, most problems could be overcome with practice and adequate support. These findings demonstrate the importance of accounting for contextual factors impacting demand in FC programming at a local level. Ongoing access to counseling for initial FC users and adopters is likely to play a critical role in successful introduction.

New female condoms in the pipeline

Male and female condoms are currently the only effective dual protection methods against unintended pregnancy and transmission of STIs and HIV. In recent years, advocacy and support to female condom (FC) programmes and increased distribution have played a significant role in highlighting to donors, policy-makers and programme managers the importance of FCs as essential tools for dual prevention. Further, the emergence of new FC products, differing in design and materials, has the potential to lower cost and improve acceptability. There are hurdles in developing new FC products, by far the greatest being the clinical studies required for regulatory purposes. However, several new designs are now available in selected countries and some are progressing through the final stages of regulatory approval, after which they will be more widely available. The new FC designs, which may also be more affordable, will increase options and choice for couples who want to use FCs as their prevention method. Here, we review the FC products that are available now and those still in development which are expected to be available within the next two to five years.

Performance of the woman's condom among couples in Shanghai, China

BACKGROUND

The Woman's Condom, a second-generation female condom, is poised for introduction in China.

STUDY DESIGN

This single-arm couples' use study was conducted in China in 2010 to assess performance and safety of the Woman's Condom and feasibility of mobile phone technology to record adherence data.

RESULTS

Sixty couples were enrolled in this study, and 59 couples completed all four of the condom uses, resulting in 234 condom uses. Two condoms were opened but not used. Total breakage was 0.85% (two non-clinical breakages). Misdirection (2%), invagination (0.85%) and slippage (1%) were consistent with data on condom failure from other studies. Total clinical failure was 4%. Fifteen mild and no serious adverse events were reported during the study.

CONCLUSIONS

This study has shown that in China, the Woman's Condom performs well. Mobile phones cannot yet replace the use of a coital log and questionnaire. Further work on effectiveness is required.

A review of the effectiveness and acceptability of the female condom for dual protection

The female condom remains the sole female-initiated method of dual protection against unintended pregnancy and sexually transmissible infections (STIs), including HIV. We reviewed published data on the effectiveness and acceptability of the female condom for protection against pregnancy and infection. Overall, use of the female condom is low and several barriers hinder the wider adoption of the use of the method. Research on effectiveness has focussed on pregnancy, STIs and biological markers of semen exposure. Although the data available suggest that female condoms (or a mixture of female and male condoms) may provide similar degrees of protection against pregnancy and STIs as do latex male condoms alone, this conclusion has not been demonstrated and thus comparative research is urgently needed.

Inclusion of the female condom in a male condom-only intervention in the sex industry in China: a cross-sectional analysis of pre- and post-intervention surveys in three study sites

OBJECTIVES

To describe female condom (FC) use, male condom (MC) use and overall levels of protected sex before, during and after FC education and promotion (using the original prototype FC) combined with MC promotion among female sex workers in three rural or small urban settings in southern China.

STUDY DESIGN

The 1-year FC intervention was conducted by local health workers through outreach to establishments where sex work is conducted. Three serial cross-sectional surveys were conducted in each study town before, during and after the intervention along with process documentation throughout the intervention period.

METHODS

Cross-sectional data from pre-intervention (baseline) and 6-month and 12-month post-intervention surveys from three study sites are used in a descriptive comparison of the context of the sex industry, outreach in two phases of intervention, and FC adoption after the intensive intervention phase in each site.

RESULTS

Approximately 75-80% of eligible women working in sex establishments, varying from 74 to 155 participants for each survey, were recruited from three study sites. After introduction and promotion of the FC along with the MC during the community public health intervention, between one-fifth and one-half of the study participants had tried the FC in the three study sites by the time of the 6-month and 12-month cross-sectional surveys. Among them, 10-30% had used the FC more than once. FC awareness increased following the intervention with much less variation across the three study sites. At baseline, 31-54% of participants across the three sites reported 100% protected sex in the last 30 days with all types of partners. At one of the sites with relatively low MC use before the intervention, the proportion of women reporting 100% protected sex in the last 30 days increased by 15%, and the proportion reporting nil protected sex in the last 30 days decreased by 13% between baseline and 12-month post-intervention surveys. More complex profiles of FC and MC use and protected sex were shown at the other two study sites, where a higher level of protection had been reached before the project started.

CONCLUSIONS

Different levels of FC adoption were identified after the 1-year FC promotion intervention through outreach to sex establishments. The input, output and outcomes of the intervention may be associated with women's demographic and risk characteristics, the local capacities of intervention staff, and other contextual factors. Further analysis of these factors will help establish the role of the FC in increasing protected sex, and provide insight into how to achieve greater FC use.