Barriers and Enablers Influencing Women's Adoption and Continuation of Vaginally Inserted Contraceptive Methods: A Literature Review

Most vaginally inserted methods have limited availability and use despite offering characteristics that align with many women's stated preferences (e.g., nonhormonal and/or on demand). The objective of this review was to identify enablers and barriers to women's adoption and continuation of vaginally inserted contraceptive methods in low- and middle-income countries (LMICs). We searched three databases (PubMed, Embase, and Web of Science) and 18 websites using keywords related to five vaginally inserted contraceptive methods (diaphragm, vaginal ring, female condom, copper intrauterine device [IUD], hormonal IUD) and terms associated with their adoption and continuation. Searches were limited to resources published between January 2010 and September 2020. Studies eligible for inclusion in our review presented results on women's use and perspectives on the enablers and barriers to adoption and continuation of the vaginally inserted contraceptive methods of interest in LMICs. Relevant studies among women's partners were also included, but not those of providers or other stakeholders. Data were coded, analyzed, and disaggregated according to a framework grounded in family planning (FP) literature and behavioral theories common to FP research and program implementation. Our initial search yielded 13,848 results, with 182 studies ultimately included in the analysis. Across methods, we found common enablers for method adoption, including quality contraceptive counseling as well as alignment between a woman's preferences and a method's duration of use and side effect profile. Common barriers included a lack of familiarity with the methods and product cost. Notably, vaginal insertion was not a major barrier to adoption in the literature reviewed. Vaginally inserted methods of contraception have the potential to fill a gap in method offerings and expand choice. Programmatic actions should address key barriers and enable voluntary use.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Views and experiences of the female condom in Australia: An exploratory cross-sectional survey of cisgender women

Background

The female condom is the only female-initiated form of protection against unintended pregnancy and sexually transmissible infections (STIs). However, use of this method in Australia is low. To better understand women’s views and experiences of the female condom, we conducted an interventional cross-sectional study.

Methods

Cisgender women ≥16 years, heterosexually active and living in New South Wales were recruited through social media advertisements and email invitations to clients of a family planning service. Eligible participants were provided with three female condoms and invited to complete a follow-up survey. Survey responses for women who attempted to use at least one female condom were summarised using counts and proportions.

Results

We recruited 556 women; few (30/556) had used the female condom before the study. There were 284 women who used, or attempted to use, a female condom during the study and completed the follow-up survey. Fifty-one percent (104/205) reported experiencing some difficulty in insertion, although only 46% (130/284) had seen an instructional demonstration. Approximately half (105/204) of women rated the sensation and comfort of the female condom as the same or better than the male condom, and 66% (137/204) reported that it provided the same or better lubrication. Approximately half of women said they would consider using the female condom again for STI prevention (51% (133/260)) or contraception (40% (103/260)), or would recommend to others (43% (112/260)).

Conclusion

Findings highlight the need for increased health promotion and education regarding use of the female condom. To increase access it will be important to address method cost and availability in Australia. Future research should explore other perspectives of this method, including among the LGBTIQ+ community.

The female condom: What do Australian women say?

BACKGROUND

The female condom is a barrier method for the prevention of sexually transmissible infections and unintended pregnancy. Uptake of this method remains low in Australia, although little research has been undertaken to explore this.

METHODS

An interventional cross-sectional study was undertaken in 2019 to explore the views and experiences of women in New South Wales. After trying the female condom, they were invited to complete an online survey and/or structured interview. Training in the use of the female condom was not provided. This paper reports on qualitative findings from open-ended survey responses and interviews.

RESULTS

In total, 284 participants completed the survey and 20 participated in an interview. Most were aware of the female condom prior to participating in the study, but few had used it previously. Four broad themes were identified from the data: (i) accessibility of the female condom, including cost and availability, (ii) supporting choice in different circumstances, (iii) aspects of empowerment and control and (iv) use of gendered language.

CONCLUSIONS

The female condom may be an acceptable option for many women in Australia. To support the choice of method and promote uptake, it will be important to increase the accessibility of the female condom by raising awareness and addressing the issues of cost and availability. Further exploration of issues regarding inclusive language and messaging in health promotion campaigns and marketing is warranted to ensure that this product is accessible for all people who may wish to use it, regardless of gender or sexuality. Similar research could be undertaken with men/partners and members of the LGBTQ+ community to explore their perspectives of the female condom. SO WHAT?: To support contraceptive choice and promote the uptake of the female condom for those who desire this method, it will be important to address the issues of cost and availability. Accessibility will also be enhanced through the consideration of inclusive language and messaging in health promotion campaigns and marketing of the female condom.

Barrier Protection Use by Adolescents During Sexual Activity

Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended pregnancy and sexually transmitted infections (STIs). This technical report discusses the new data and trends in adolescent sexual behavior and barrier protection use. Since 2017, STI rates have increased and use of barrier methods, specifically external condom use, has declined among adolescents and young adults. Interventions that increase availability of or accessibility to barrier methods are most efficacious when combined with additional individual, small-group, or community-level activities that include messages about safer sex. Continued research informs public health interventions for adolescents that increase the consistent and correct use of barrier methods and promote dual protection of barrier methods for STI prevention together with other effective methods of contraception.

Perceived barriers and facilitators to female condoms among UK based healthcare professionals

OBJECTIVES

The female condom (FC) is an effective strategy against sexually transmitted infections (STIs) in susceptible women and men who have sex with men. FCs are the only female-initiated dual protection method that protects against both STIs and unintended pregnancy. As healthcare professionals (HCPs) are a key element in the promotion of contraceptive use, it is important to examine attitudes towards FCs among this group. Study participants: 15 male and female HCPs aged between 22 and 57 years recruited from sexual and reproductive health settings located in Brighton, London, and Glasgow. Sampling method: Purposive sampling with targeted advertisements (newsletters and bulletins). Study design: face-to-face and telephone interviews with sexual health HCPs. Main outcome measure: potential barriers and facilitators to FCs in the UK. Data were analysed thematically to identify common views and perspectives.

RESULTS

FCs were thought to be unacceptable to most women due to stigma, design, negative visual appeal, insertion difficulties and lack of familiarity. The perceived unavailability and higher cost of FCs, in comparison to male condoms, are major barriers to their use.

CONCLUSIONS

HCPs are reluctant to promote FCs, often due to the perceived social stigma surrounding FCs. Further education and promotion are needed to increase acceptability and correct usage. Future research needs to explore strategies to increase the acceptability of FCs among women, men who have sex with men and HCPs.

Intimate Partner Violence and Pre-exposure Prophylaxis (PrEP): A Rapid Review of Current Evidence for Women's HIV Prevention

Pre-exposure prophylaxis (PrEP) is a valued component of HIV prevention and increasing attention is focusing on women's PrEP use. Common HIV prevention options (e.g., condoms) remain underused and fail to consider the context of intimate partner violence (IPV). PrEP presents an opportunity to expand viable options for women. A systematic rapid review using key word searches of PubMed and proceedings from six national and international conferences related to HIV, women's health, or interpersonal violence identified nine studies which met set inclusion criteria. Studies were coded using a structured abstraction form and summarized according to relevant themes. IPV was found to have implications on women's interest and willingness to use PrEP, partner interference or interruptions in PrEP use, and adherence. Findings indicate a dearth of research on women's PrEP use and IPV and highlight the urgency for research, public heath practice, and policy attention around the HIV risk context and needs of women who experience IPV.

Female Condom Use and Its Acceptability Among HIV-serodiscordant Couples in China

Intimate partners of people living with HIV are at risk of HIV infection. We assessed the acceptability of female condom use among 89 married, heterosexual, HIV-serodiscordant couples from Sichuan and Hunan provinces in China for this prospective observational cohort study. Participants used female condoms for 3 months, reporting use and attitudes in written logs and questionnaires. At the end of the study, 58.4% of couples expressed willingness to continue using female condoms. Factors associated with willingness to use female condoms were (a) the female partner reporting having experienced forced sex by the male partner, (b) applying a lubricant to the penis, (c) understanding the correct application method, (d) being married more than 20 years, and (e) experiencing no difficulty during the first use. Most HIV-serodiscordant couples found female condoms to be acceptable. Increasing access to female condoms could be an acceptable alternative barrier method to male condoms for preventing HIV transmission.

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.

The evaluation of the Woman's Condom marketing approach: What value did peer-led interpersonal communication add to the promotion of a new female condom in urban Lusaka?

During a mass media campaign accompanying the launch of the Maximum Diva Woman's Condom (WC) in Lusaka, Zambia, a cluster-randomized evaluation was implemented to measure the added impact of a peer-led interpersonal communication (IPC) intervention on the awareness and uptake of the new female condom (FC). The WC and mass media campaign were introduced simultaneously in 40 urban wards in April 2016; half of the wards were randomly assigned to the treatment (IPC intervention) with cross-sectional surveys conducted before (n = 2,364) and one year after (n = 2,430) the start of the intervention. A pre-specified intention-to-treat (ITT) analysis measured the impact of randomization to IPC at the community level. In adjusted ITT models, there were no statistically significant differences between intervention and control groups. Due to significant implementation challenges, we also conducted exploratory secondary analyses to estimate effects among those who attended an IPC event (n = 66) using instrumental variable and inverse probability weighting analyses. In addition to increases in FC identification (IPC attendees had higher reported use of any condom, improved perceptions of FC's, and were more likely to have discussed contraceptive use with their partner as compared to non-attendees). The introduction of a new FC product combined with an IPC intervention significantly increased general knowledge and awareness in the community as compared to media alone, but did not lead to detectable community level impacts on other primary outcomes of interest. Observational evidence from our study suggests that IPC attendance is associated with increased use and negotiation. Future studies should explore the intensity and duration of IPC programming necessary to achieve detectable community level impacts on behavior. Trial Registration: AEARCTR-0000899.

Opportunities and challenges for the introduction of a new female condom among young adults in urban Zambia

Background

Expanding contraceptive method choices for sexually active youth is critical to prevent STIs/HIV and unintended pregnancies. However, preferences and decision making around contraception among young adults are not well understood. A new female condom (FC), the Woman’s Condom (WC), features an improved design and is marketed as a premium product at a higher price point. We conducted a qualitative study to examine the underlying knowledge, attitudes, and perceptions around the FC generally, the WC specifically, and to explore the opportunities and challenges of introducing the WC to young adults in urban Zambia.

Methods

Thirty focus group discussions comprised of 245 men and women aged 18–24 years were facilitated by local moderators in Lusaka, Zambia between August and December 2016. Data were analyzed using thematic content analysis using ATLAS.ti (Version 7.5.17).

Results

While interest in the newly launched WC was high, few participants recognized it, so discussion was framed around FCs more generally. The decision to use a FC is challenged by misconceptions regarding safety and correct use, cost, and women’s limited power over decision making in relationships. Participants also reported low availability of the product. Several opportunities for FC uptake were discussed, including the perception that FCs provide better sensation during intercourse compared with male condoms, and women reported enthusiasm for the opportunity to be the partner responsible for contraception. Some women expressed interest in the WC in order to ensure it was not tampered with by their partner, a practice commonly reported by both genders that reflects high levels of mistrust.

Conclusions

Findings suggest the FC, including the new WC, has potential to increase gender equity by giving women a product they are comfortable buying and being able to control to ensure correct use; however, future programming should address high perceived cost of the WC and women’s limited decision making power in relationships. Findings also highlight the need for interventions that include product demonstration and promote the WC as a method that provides better sensation during sex than male condoms. To increase voluntary uptake, the challenges identified here should be incorporated into future social marketing campaigns.

Pathways from Resilient Coping to Safer Sex Communication Among African, Caribbean, and Black Women in Toronto, Canada: Results from a Cross-sectional Survey

PURPOSE

African, Caribbean, and Black (ACB) women in Canada are disproportionately impacted by HIV and other sexually transmitted infections. Although there is reported suboptimal consistent condom use with ACB women, limited research has explored safer sex communication among this population. Coping frameworks highlight the role that resilient coping and condom use self-efficacy may play in facilitating safer sex communication. Structural perspectives stress the need to explore associations between HIV vulnerabilities and food insecurity. We examined pathways from resilient coping to safer sex communication through the mediator of condom use self-efficacy among ACB women in Toronto.

METHOD

We conducted a cross-sectional survey with a purposive sample of ACB women aged 16 and older across Toronto, Canada. We conducted path analysis to test the direct effects of resilient coping on safer sex communication, and indirect pathways through the mediator (condom use self-efficacy) while controlling for food insecurity.

RESULTS

Participant (n = 80; mean age 27, SD 7.93) ethnicities included African (58.8%, n = 47), Caribbean (30%, n = 24), and others (11.3%, n = 9). Participants with food security reported significantly higher safer sex communication. We found no direct effect of resilient coping on safer sex communication. Findings support the hypothesized mediation process; resilient coping was associated with condom use self-efficacy, which in turn was associated with safer sex communication.

CONCLUSION

Findings that condom use self-efficacy mediated the association between resilient coping and safer sex communication align with theoretical assertions of the protective role of adaptive coping strategies. Findings can inform tailored HIV and STI preventive interventions with ACB women.

Effectiveness of female condom in preventing HIV and sexually transmitted infections: a systematic review protocol

INTRODUCTION

The HIV pandemic continues to evolve with young women being the most vulnerable group to acquire infection. The presence of sexually transmitted infections (STIs) further enhances HIV susceptibility and also leads to long-term complications such as infertility and cervical cancer. The female condom is a self-initiated method for STI and HIV prevention but there are controversies on its effects. We aim to assess the effectiveness, safety and acceptability of the use of female condoms for prevention of STI and HIV acquisition among women.

METHODS AND ANALYSIS

We will search Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Scopus, WHO International Clinical Trials Registry and reference lists of relevant publications for potentially eligible studies. We will screen search outputs, select eligible studies, extract data and assess risk of bias in duplicate; resolving discrepancies through discussion and consensus or arbitration. We will combine data from clinically homogenous studies in a fixed effect meta-analysis and assess the certainty of the evidence using the method for Grading of Recommendations Assessment, Development and Evaluation. We registered the planned systematic review with the International Prospective Register of Systematic Reviews (PROSPERO) in March 2018 and will finalise the search strategy in August 2018; conduct the searches and select eligible studies between August and October 2018; and collect data, conduct statistical analyses and prepare and submit the manuscript for consideration by a peer-reviewed journal between November 2018 and April 2019.

ETHICS AND DISSEMINATION

We will use publicly available data; hence no formal ethical approval is required for this review. We will disseminate the findings of this review through conference presentations and publication in an open-access peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018090710.

Perspectives of South African youth in the development of an implant for HIV prevention

INTRODUCTION

Implants are a new dosage form in development for HIV pre-exposure prophylaxis (PrEP) with potential for high adherence given that they are provider-administered and are intended for long-acting protection. Integrating end-user preference into early stage product development may further overcome challenges with future product uptake and adherence. Hence, we sought to optimize the design of a PrEP implant in early-stage development by gathering opinions about implant attributes from potential end-users in South Africa.

METHODS

We conducted 14 focus group discussions (FGDs) with young women and men aged 18 to 24 in Cape Town and Soshanguve, South Africa, inviting participants into discussion as co-designers. FGDs were homogenous by gender and previous implant experience. During FGDs, we showed prototype devices and followed a semi-structured guide with questions on history of contraceptive implant use, preferences for physical characteristics of an implant, implant biodegradability, insertion process, participant-driven ideas for implant design, and social adoption considerations. FGDs were facilitated in English, isiXhosa, Tswana, isiZulu, or Tsonga, audio-recorded, transcribed into English, and qualitatively coded and analysed.

RESULTS

In this qualitative sample of 105 youth (68 women and 37 men), 58 participants were from Soshanguve and 47 from Cape Town, and 23% had previously used contraceptive implants. Participants expressed preferences for several implant design features; specifically, longer duration (≥6 months) was more important to most participants than the size or number of devices implanted. A majority preferred a flexible versus stiff implant to minimize palpability, thereby increasing discreetness and comfort. Nearly all participants favoured a biodegradable implant to avoid removal and thus reduce clinic visits. Concerns about the implant centred on its possible side effects and the "plastic" look of the prototype displayed for demonstration.

CONCLUSIONS

This study offers preliminary insights into an implant for HIV prevention that provides long-lasting protection may be well received among young South Africans. Additionally, flexibility, discreetness, and biodegradability may increase acceptability of the implant. Such end-user feedback is being incorporated into current implant designs in the hope of creating an effective long-acting PrEP product that is likely to achieve high uptake and adherence in target populations.

[From evidence to action: challenges for the Brazilian Unified National Health System in offering pre-exposure prophylaxis (PrEP) for HIV to persons with the greatest vulnerability]

Pre-exposure prophylaxis (PrEP) has been considered a promising strategy for controlling the global HIV epidemic. However, it is necessary to translate the knowledge accumulated from clinical trials and demosntration studies to the reality of health services and the groups most vulnerable to infection in order to achieve broad coverage with PrEP. The article proposes a reflection on this challenge, focusing on three dimensions: users of prophylaxis, with an emphasis on the contexts of sexual practices and the potential exposures to HIV; the advantages of prophylaxis as compared to other methods and the challenges for protective and safe use; and health services, considering the organizational principles to ensure greater success in the supply and incorporation of PrEP as part of combination prevention strategies. The following principles were analyzed: uniqueness of care, freedom of choice and non-hierarchization of prevention methods, sexual risk management, scheduling flexibility, and complementary and multidisciplinary care. These principles can foster organization of the health service and care, facilitating linkage and retention in care. Some comments were offered on the relative incompatibility between the existing structure of services and the Brazilian Ministry of Health guidelines for offering PrEP. The conclusion was that the success of PrEP as a public health policy depends on two essential factors: ensuring that health services are culturally diverse settings, free of discrimination, and the intensification of community-based interventions, including social networks, in order to reduce inequalities in access to PrEP and health services as a whole.

A pilot study on the functional performance and acceptability of an innovative female condom (Wondaleaf®) in Malaysia

Background

Female condom (FC) has been available for over 30 years, but it still lacks wide acceptability. To overcome misdirection and invagination occurring in FC and to provide a wider area of protection, Wondaleaf^® (WL), a new-generation adhesive FC, was recently invented. This pioneering study sought to assess the acceptability and functional performance of WL among Malaysian women.

Methods

A mixed method survey was conducted in three cities of Malaysia, recruiting sexually active heterosexual women, aged 18–50, by snowball sampling method. Participants were provided with WL and initially surveyed to rate its performance in five coital usages over 2 months. After that, the participants underwent a second survey to rate their satisfaction and acceptability toward WL. Descriptive statistics on clinical failure rates were tabulated with correlational analysis performed to identify major variables contributing to WL’s functional performance and acceptability.

Results

Out of the 51 enrolled participants, 31 women completed the required surveys. WL’s total clinical failure rate was 2.60% (out of 155 condom uses) with above-average ratings of functional performance. The ease of use significantly correlated with ratings of no slippage and no misdirection. The confidence in WL’s safety features significantly correlated with a sense of empowerment and protection.

Conclusion

WL has a relatively low risk of clinical failures and an overall favorable acceptability among Malaysian women. However, this study also showed that its future usage largely depends on partner acceptability. It may have the potential of complementing the existing barrier toward contraceptive use. Further studies are needed to understand the global acceptability of WL.

The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review

A spectrum of diverse prevention methods that offer high protection against HIV has posed the following challenge: how can national AIDS policies with high coverage for prevention and treatment make the best use of new methods so as to reverse the current high, and even rising, incidence rates among specific social groups? We conducted a narrative review of the literature to examine the prevention methods and the structural interventions that can have a higher impact on incidence rates in the context of socially and geographically concentrated epidemics. Evidence on the protective effect of the methods against sexual exposure to HIV, as well as their limits and potential, is discussed. The availability and effectiveness of prevention methods have been hindered by structural and psychosocial barriers such as obstacles to adherence, inconsistent use over time, or only when individuals perceive themselves at higher risk. The most affected individuals and social groups have presented limited or absence of use of methods as this is moderated by values, prevention needs, and life circumstances. As a result, a substantial impact on the epidemic cannot be achieved by one method alone. Programs based on the complementarity of methods, the psychosocial aspects affecting their use and the mitigation of structural barriers may have the highest impact on incidence rates, especially if participation and community mobilization are part of their planning and implementation.

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.

Knowledge, acceptance and utilisation of the female condom among women of reproductive age in Ghana

Background

The female condom (FC) is the only safe and effective female-initiated method that provides simultaneous protection against unintended pregnancy as well as sexually transmitted infections (STIs), including HIV/AIDS. Knowledge of FC use among women and the perceptions and attitudes towards condom use can contribute to its uptake as an important public health strategy for HIV prevention in Ghana. However, there is a dearth of empirical evidence in this area of public health research to inform interventions. This study seeks to examine women’s knowledge, acceptance and utilisation of the FC and factors that influence its acceptance and utilisation.

Methods

A descriptive cross-sectional survey design was used and a total of 380 females between the ages of 15 and 49 years were sampled from the Hohoe Municipality of the Volta Region, Ghana. A self-administered structured questionnaire measuring the study variables was used, and frequencies, percentages and Chi Square tests were used to analyse the data.

Results

There is low level of FC use among the women as less than half (48.4%) of the sample were aware of the FC. It was further observed that 21.1, 21.8 and 11.1% of the sample reported friends, media and a public lecture as their sources of knowledge of the FC respectively. It was also observed that there is a low level of FC acceptance and utilisation, and also limited access to the FC from nearby shops/pharmacies (1.8%) and health centres (7.4%).

Conclusions

There is a generally low level of FC awareness, knowledge, acceptance and utilisation and therefore, there is the need for increased public education on the FC and its benefits to women in preventing unwanted pregnancies and sexually transmitted diseases (STDs).

Development and Psychometric Properties of a Condom Use and Its Cognitive Determinants Questionnaire (CUCDQ)

AIM

The aim of this study was to assess the psychometric properties of Condom Use and its Cognitive Determinants Questionnaire (CUCDQ) among married women in Tabriz, Iran.

MATERIALS AND METHODS

In this cross-sectional study, applying multistage cluster sampling 388 married women were recruited to participate in the study. A comprehensive literature review was conducted to develop CUCDQ. Face, content, and construct validity, as well as reliability, were investigated.

RESULTS

Principal component factor analysis with varimax rotation demonstrated a six factors structure as the best solution [Bartlett's Test of Sphericity (Approx. Chi-Square= 4193.07, df= 780, p<0.001); KMO= 0.815] which explained 43.13% of all the variance between the items. CUCDQ represented a proper validity, reliability, simplicity and functionality.

CONCLUSION

CUCDQ may be helpful for family health care providers and family planning decision makers in precise assessing the behavioural, psychological, and educational factors related to condom use. This scale may be useful in a various range of studies including family planning or STIs prevention studies in different communities. Future research is recommended to assess the different dimensions of the tool in different communities.

Impact of communication strategies to increase knowledge, acceptability, and uptake of a new Woman's Condom in urban Lusaka, Zambia: study protocol for a randomized controlled trial

BACKGROUND

Globally, 220 million women experience an unmet need for family planning. A newly designed female condom, the Woman's Condom (WC), has been developed featuring an improved design. It is the first dual-protection, female-initiated contraceptive that is a premium, higher price point product. However, market availability alone will not increase uptake. In February 2016 the WC will be distributed with a strong media campaign and interpersonal communication (IPC) outreach intervention. The impact of these on knowledge, acceptability, and use of the WC will be measured.

METHODS/DESIGN

A baseline survey of 2314 randomly selected 18- to 24-year-old sexually active men and women has been conducted. The WC and mass media will be introduced throughout 40 urban wards in and surrounding Lusaka, Zambia. The baseline survey will serve as a quasi-control arm to determine the impact of introducing the WC with mass media. Half of the wards will be randomly allocated to additionally receive the IPC intervention. A single-blind randomized controlled trial will determine the impact of the IPC intervention on knowledge, uptake, and use of the WC. After one year, another 2314 individuals will be randomly selected to participate in the endline survey. We hypothesize that (1) the distribution and media campaign of the WC will increase overall condom use in selected urban wards, and specifically use of the WC; (2) the IPC intervention will significantly impact knowledge, acceptability, and use of the WC. The primary outcome measures are use of the WC, use of any condom, and willingness to use the WC. Secondary outcomes include measures of knowledge, acceptability, and choice of contraception. Odds ratios will be estimated to measure the effect of the intervention on the outcomes with 95% confidence intervals. All analyses will be based on the intention-to-treat principle.

DISCUSSION

Increasing uptake of dual prevention measures (such as the WC) may reduce incidence of sexually transmitted infections/HIV and unplanned pregnancies. It is important to ensure young, urban adults have access to new contraceptive methods; and, understanding how mass media and IPC impact contraceptive knowledge, acceptability, and use is critical to reduce unmet need.

TRIAL REGISTRATION

AEARCTR-0000899 . Registered on 26 October 2015.

New Biomedical Technologies and Strategies for Prevention of HIV and Other Sexually Transmitted Infections

Sexually transmitted infections remain to be of public health concern in many developing countries. Their control is important, considering the high incidence of acute infections, complications and sequelae, and their socioeconomic impact. This article discusses the new biomedical technologies and strategies for the prevention of HIV and other sexually transmitted infections.

Short-Term Acceptability of the Woman's Condom among Married Couples in Shanghai

Background. The Woman's Condom, a second-generation female condom designed for acceptability, is poised for introduction in China. Method. This single-arm study was conducted among 60 couples in China in 2010 to assess acceptability of the Woman's Condom. Results. Male participants reported that ease of handling, inserting, and removing the device improved significantly from first to fourth use. Female and male participants reported that comfort during insertion, feel of lubricant during insertion, comfort/fit of outer ring during use, and overall comfort improved significantly from first to fourth use. Further, at fourth use, female participants reported significant improvement in the comfort of the feel of the condom material and lubricant. Female and male participants reported that satisfaction with stability and sensation during sex and ability to achieve orgasm improved significantly from first to fourth use. At fourth use, female participants reported statistically significant improvement in sensation compared to using nothing. A majority of participants (78%) stated that they would use the Woman's Condom in the future, primarily due to its dual protection profile. Conclusion. This study has shown that, in China, the Woman's Condom appears to be acceptable to married couples. User experience contributes to improvement in many aspects of device acceptability.

The Potential of Pre-Exposure Prophylaxis for Women in Violent Relationships

HIV and intimate partner violence (IPV) are significant intersecting threats to women's health. Women in violent relationships have few feasible HIV risk reduction options as traditional prevention methods are largely dependent on a partner's cooperation. The purpose of this review is to explore potential benefits and drawbacks of pre-exposure prophylaxis (PrEP) use among women in the United States experiencing IPV. Advantages of PrEP use in this population include the potential for covert or autonomous use, coital independence, dual protection against sexual and injection risk, and facilitated connections to social services. A number of barriers, however, may interfere with the effective use of PrEP, including partner resistance, cost, frequent medical visits, gendered norms regarding sexuality, and stigma. To realize its potential for women in violent relationships, it will be necessary to incorporate PrEP into behavioral and structural interventions that encourage uptake, facilitate adherence, ensure women's safety, and challenge existing gender norms.

Accessibility and availability of the Female Condom2: Healthcare provider's perspective

BACKGROUND

Despite the acceptability of the Female Condom2 (FC2) as a contraceptive method by some women, it remains inaccessible and unavailable to the majority of women because of affordability, training, distribution and marketing strategies. The FC2 affords women dual protection and the option to negotiate safe sex.

OBJECTIVE

This paper explores and describes the perspective of the healthcare providers regarding accessibility and availability of the FC2 as a contraceptive method in the Tshwane district.

METHOD

The study used an explorative, descriptive, and qualitative design. Data were collected from 26 healthcare providers who were purposively selected. In-depth face-to-face interviews were conducted with these healthcare providers in the Tshwane district. Tesch's method of open coding was used for data analysis.

RESULTS

Two main themes emerged, namely, the availability of the FC2 and the knowledge o fthe healthcare providers. The findings of this study indicated that the availability of the FC2 remains a challenge because of factors such as lack of affordability, inefficient procurement and lack of distribution measures. The condoms are also not available at strategic points so as to ensure accessibility. Insufficient knowledge amongst healthcare providers was described as a barrier which affects the quality of training of the service users.

CONCLUSIONS

It is evident that the FC2 is not yet available in all healthcare settings, therefore strategies to safeguard accessibility and availability of the FC2 as a contraceptive method are recommended.

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.

Female Condom Use and Adoption Among Men and Women in a General Low-Income Urban U.S. Population

HIV prevention is increasingly focused on antiretroviral treatment of infected or uninfected persons. However, barrier methods like male condoms (MC) and female condoms (FC) remain necessary to achieve broad reductions in HIV and other sexually transmitted infections (STI). Evidence grows suggesting that removal of basic obstacles could result in greater FC use and reduced unprotected sex in the general population. We conducted four annual cross-sectional surveys (2009-2012) of urban residents (N = 1614) in low-income neighborhoods of a northeastern U.S. city where prevalence of HIV and other STIs is high. Findings indicate slow FC uptake but also heterosexual men's willingness to use them. Factors associated with men's and women's FC use included positive FC attitudes, network exposure, and peer influences and norms. These results suggest that men can be supporters of FC, and reinforce the need for targeted efforts to increase FC use in both men and women for HIV/STI prevention.

Screening and prevention of sexually transmitted infections

Sexually transmitted infections (STIs) are common and costly, in part because they are asymptomatic and result in serious complications. Primary care clinicians can easily diagnose and effectively treat most STIs. Clinicians should screen patients for STIs based on high-risk behaviors, and consult with local public health officials to adapt national screening guidelines to local epidemiology. Clinical encounters involving STI screening are opportunities to counsel patients on risk behaviors, and vaccinate against human papillomavirus and hepatitis B. Electronic health records and mobile phone apps show promise for improving the clinical care of STIs.

Towards an integrated framework for accelerating the end for the global HIV epidemic among young people

For decades the HIV epidemic has exacted an enormous toll worldwide. However, trend analyses have discerned significant declines in the overall prevalence of HIV over the last two decades. More recently, advances in biomedical, behavioural, and structural interventions offer considerable promise in the battle against generalised epidemics. Despite advances in the prevention of transmission and new infections, morbidity and mortality of HIV among young people remains a considerable concern for individuals, couples, families, communities, practitioners, and policy makers around the globe. To accelerate the end of the global HIV epidemic among young people, we must merge existing efficacious interventions with more novel, cost-effective implementation strategies to develop integrated, multilevel combination interventions. The benefits of conceptualising the HIV epidemic more broadly and adopting ecological frameworks for the development of HIV prevention programmes are critical.

Behavioral interventions for improving condom use for dual protection

BACKGROUND

Unprotected sex is a major risk factor for disease, disability, and mortality in many areas of the world due to the prevalence and incidence of sexually transmitted infections (STI) including HIV. The male condom is one of the oldest contraceptive methods and the earliest method for preventing the spread of HIV. When used correctly and consistently, condoms can provide dual protection, i.e., against both pregnancy and HIV/STI.

OBJECTIVES

We examined comparative studies of behavioral interventions for improving condom use. We were interested in identifying interventions associated with effective condom use as measured with biological assessments, which can provide objective evidence of protection.

SEARCH METHODS

Through September 2013, we searched computerized databases for comparative studies of behavioral interventions for improving condom use: MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, OpenGrey, COPAC, ClinicalTrials.gov, and ICTRP. We wrote to investigators for missing data.

SELECTION CRITERIA

Studies could be either randomized or nonrandomized. They examined a behavioral intervention for improving condom use. The comparison could be another behavioral intervention, usual care, or no intervention. The experimental intervention had an educational or counseling component to encourage or improve condom use. It addressed preventing pregnancy as well as the transmission of HIV/STI. The focus could be on male or female condoms and targeted to individuals, couples, or communities. Potential participants included heterosexual women and heterosexual men.Studies had to provide data from test results or records on a biological outcome: pregnancy, HIV/STI, or presence of semen as assessed with a biological marker, e.g., prostate-specific antigen. We did not include self-reported data on protected or unprotected sex, due to the limitations of recall and social desirability bias. Outcomes were measured at least three months after the behavioral intervention started.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.

MAIN RESULTS

Seven studies met our eligibility criteria. All were randomized controlled trials; six assigned clusters and one randomized individuals. Sample sizes for the cluster-randomized trials ranged from 2157 to 15,614; the number of clusters ranged from 18 to 70. Four trials took place in African countries, two in the USA, and one in England. Three were based mainly in schools, two were in community settings, one took place during military training, and one was clinic-based.Five studies provided data on pregnancy, either from pregnancy tests or national records of abortions and live births. Four trials assessed the incidence or prevalence of HIV and HSV-2. Three trials examined other STI. The trials showed or reported no significant difference between study groups for pregnancy or HIV, but favorable effects were evident for some STI. Two showed a lower incidence of HSV-2 for the behavioral-intervention group compared to the usual-care group, with reported adjusted rate ratios (ARR) of 0.65 (95% CI 0.43 to 0.97) and 0.67 (95% CI 0.47 to 0.97), while HIV did not differ significantly. One also reported lower syphilis incidence and gonorrhea prevalence for the behavioral intervention plus STI management compared to the usual-care group. The reported ARR were 0.58 (95% CI 0.35 to 0.96) and 0.28 (95% CI 0.11 to 0.70), respectively. Another study reported a negative effect on gonorrhea for young women in the intervention group versus the control group (ARR 1.93; 95% CI 1.01 to 3.71). The difference occurred among those with only one year of the intervention.

AUTHORS' CONCLUSIONS

We found few studies and little clinical evidence of effectiveness for interventions promoting condom use for dual protection. We did not find favorable results for pregnancy or HIV, and only found some for other STI. The overall quality of evidence was moderate to low; losses to follow up were high. Effective interventions for improving condom use are needed to prevent pregnancy and HIV/STI transmission. Interventions should be feasible for resource-limited settings and tested using valid and reliable outcome measures.

Promoting female condoms in the sex industry in 4 towns of Southern China: context matters

BACKGROUND

The female condom (FC) is an effective tool for dual protection, but it remains underused. Individual and contextual reasons need to be explored.

OBJECTIVE

The aim of this study was to compare individual and contextual characteristics of FC multitime users, 1-time users, and nonusers among women in the sex industry of 4 study sites in China.

METHODS

A standardized 1-year FC intervention along with male condoms was implemented through outreach to sex establishments. Three serial cross-sectional surveys were conducted at baseline and after each of two 6-month intervention phases.

RESULTS

A total of 445, 437, and 290 eligible women were interviewed at 3 cross-sectional surveys, respectively. At the first and second postintervention surveys, 83.3% and 81.7% of women reported knowing about FC, and 28.8% and 36.6% had used FC at least once. Women who used FC multiple times reported less unprotected sex than nonusers in the last 30 days (3.0% vs. 17.2% at first and 3.2% vs. 16.8% at second postintervention survey, P < 0.01). Polytomous logistic regression showed that both 1-time and multitime users were more likely to come from one particular site (approximately 3 times more than the reference site). Higher intervention scores (adjusted odds ratio, 1.8-4.0) and working in boarding houses (adjusted odds ratio, 3.4) were associated with FC use.

CONCLUSIONS

Adding FC into male-condom-only intervention may reduce unprotected sex among women in sex establishments in rural and small urban areas of China. Adoption of FC may be related not only to intervention exposure but also to contextual factors associated with study site and type of sex establishments.

Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia

The HIV Prevention Trials Network (HPTN) is conducting the HPTN 071 (PopART) study in 21 communities in Zambia and South Africa with support from a consortium of funders. HPTN 071 (PopART) is a community-randomized trial of a combination prevention strategy to reduce HIV incidence in the context of the generalized epidemic of southern Africa. The full PopART intervention strategy is anchored in home-based HIV testing and facilitated linkage of HIV-infected persons to care through community health workers and universal antiretroviral therapy for seropositive persons regardless of CD4+ cell count or HIV viral load. To further reduce the risk of HIV acquisition among uninfected individuals, the study aims to expand voluntary medical male circumcision, diagnosis and treatment of sexually transmitted infections, behavioral counseling, and condom distribution. The full PopART intervention strategy also incorporates promotion of other interventions designed to reduce HIV and tuberculosis transmission, including optimization of the prevention of mother-to-child HIV transmission and enhanced individual and public health tuberculosis services. Success for the PopART strategy depends on the ability to increase coverage for the study interventions whose uptake is a necessary antecedent to a prevention effect. Processes will be measured to assess the degree of penetration of the interventions into the communities. A randomly sampled population cohort from each community will be used to measure the impact of the PopART strategy on HIV incidence over 3 years. We describe the strategy being tested and progress to date in the HPTN 071 (PopART) study.

Who are the preferential targets for intervention programs related to the female condom among sex workers in southern China?

The authors used a cluster analysis approach to investigate which female sex workers (FSW) are preferential targets for female condom (FC) intervention programs in southern China. Cross-sectional 6-month (N = 316) and 12-month (N = 217) postintervention surveys of FSW were analyzed. Based on FC attitudes and beliefs, initially suggesting FC use to a partner, practicing insertion, total times ever used, and willingness to use in the future, cluster analysis apportioned women into two clusters, with 50.6% and 58.1% of participants in the likely future FC users group at 6 months and 12 months, respectively. Likely future FC users tended to be from boarding houses, older, currently or previously married, experienced with childbirth, with current multiple sex partners, longer history of sex work, and more unprotected sexual encounters. Focusing FC programs on sectors of the community with more FSW who are likely to use FC may be more cost-effective for enhancing FC acceptability and usage.

Enhancing acceptability and use of sexual barrier products among HIV concordant and discordant couples

Strategies to prevent HIV transmission may benefit from addressing both individual and dyadic factors. This study compared the impact of group and individual interventions on the acceptability of sexual barrier products among HIV sero-concordant and discordant couples, and evaluated the contribution of couple members' perceived product acceptability to their sexual barrier use. Participants (n = 216 couples) were multicultural couples in Miami, Florida. Longitudinal multilevel modeling and the actor-partner interdependence model were used for analyses. Product acceptability increased more among female group participants, and acceptability of male condoms increased more among sero-discordant couples in the group. Additionally, acceptability of products associated with prevention of STDS/HIV and pregnancy increased more among sero-concordant couples in the group condition. Both actor and partner product acceptability predicted use. Results support the use of group interventions targeting both partners in relationships in prevention programs designed to enhance sexual barrier use.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Condom-use intentions and the influence of partner-related barriers among women at risk for HIV

AIMS AND OBJECTIVES

To examine intentions to engage in condom use and potential partner-related barriers to condom use, including intimate partner violence (IPV), low levels of sexual relationship power and perceptions of monogamy, among women at risk for HIV.

BACKGROUND

In the United States, women account for approximately one in four new HIV infections. Despite the effectiveness of consistent condom use, women often confront biological, cultural and psychosocial barriers that limit their ability to engage in condom-use.

DESIGN

Cross-sectional, quantitative study.

METHODS

Participants (N = 90) were recruited from a domestic violence shelter, a domestic violence support organisation and an obstetrics/gynaecology clinic in Philadelphia, PA. Data were collected by questionnaires to assess women's condom-use intentions, actual condom-use behaviour, sexual partner risk factors, experience of IPV, level of sexual relationship power and perceptions of monogamy.

RESULTS

Fifty-eight per cent of participants (n = 52) indicated a difference between their preference and intentions to use condoms vs. their actual use, with 62% (n = 32) using condoms less frequently than they would like. Significant differences in condom use emerged for women with low vs. high sexual relationship power and women who reported being in a monogamous relationship vs. those who did not. Of particular concern, a majority of these relationships were with high-risk partners, further increasing women's already elevated risk of acquiring HIV.

CONCLUSIONS

Condom use is a multifaceted issue, particularly in sexual relationships involving power differentials and perceived monogamy. Condom use was complicated by women's own preferences, sexual relationship power differentials and by the perceived exclusivity of the relationship with their sexual partners.

RELEVANCE TO CLINICAL PRACTICE

These findings have important implications for nurses as they are uniquely positioned to facilitate HIV risk reduction among their patients through the discussion of sexual health issues and barriers to negotiating condom use that women may confront.

Acceptability of condom promotion and distribution among 10-19 year-old adolescents in Mpwapwa and Mbeya rural districts, Tanzania

Background

The HIV/AIDS pandemic remains a leading challenge for global health. Although condoms are acknowledged for their key role on preventing HIV transmission, low and inappropriate use of condoms persists in Tanzania and elsewhere in Africa. This study assesses factors affecting acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural districts of Tanzania.

Methods

Data were collected in 2011 as part of a larger cross-sectional survey on condom use among 10–19 year-olds in Mpwapwa and Mbeya rural districts of Tanzania using a structured questionnaire. Associations between acceptability of condom promotion and distribution and each of the explanatory variables were tested using Chi Square. Multivariate logistic regression model was used to examine independent predictors of the acceptability of condom promotion and distribution using STATA (11) statistical software at 5% significance level.

Results

Mean age of the 1,327 adolescent participants (50.5% being males) was 13.5 years (SD = 1.4). Acceptance of condom promotion and distribution was found among 37% (35% in Mpwapwa and 39% in Mbeya rural) of the adolescents. Being sexually active and aged 15–19 was the strongest predictor of the acceptability of condom promotion and distribution (OR = 7.78, 95% CI 4.65-12.99). Others were; not agreeing that a condom is effective in preventing transmissions of STIs including HIV (OR = 0.34, 95% CI 0.20-0.56), being a resident of Mbeya rural district (OR = 1.67, 95% CI 1.28-2.19), feeling comfortable being seen by parents/guardians holding/buying condoms (OR = 2.20, 95% CI 1.40-3.46) and living with a guardian (OR = 1.48, 95% CI 1.08-2.04).

Conclusion

Acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural is low. Effect of sexual activity on the acceptability of condom promotion and distribution is age-dependent and was the strongest. Feeling comfortable being seen by parents/guardians buying or holding condoms, perceived ability of condoms to offer protection against HIV/AIDS infections, district of residence and living arrangements also offered significant predictive effect. Knowledge of these factors is vital in designing successful and sustainable condom promotion and distribution programs in Tanzania.

Condom use: still a sexual health staple

This article introduces and summarizes the contents of this special edition. Given the exceptional potential of condoms to avert epidemics of sexually transmitted infections and teen or unintended pregnancy - even in low-resource environments - this in-depth examination of current knowledge, practice, and issues with condoms and their use is an important asset for educators and practitioners worldwide.

Paying for prevention: challenges to health insurance coverage for biomedical HIV prevention in the United States

Reducing the incidence of HIV infection continues to be a crucial public health priority in the United States, especially among populations at elevated risk such as men who have sex with men, transgender women, people who inject drugs, and racial and ethnic minority communities. Although most HIV prevention efforts to date have focused on changing risky behaviors, the past decade yielded efficacious new biomedical technologies designed to prevent infection, such as the prophylactic use of antiretroviral drugs and the first indications of an efficacious vaccine. Access to prevention technologies will be a significant part of the next decade's response to HIV and advocates are mobilizing to achieve more widespread use of these interventions. These breakthroughs, however, arrive at a time of escalating healthcare costs; health insurance coverage therefore raises pressing new questions about priority-setting and the allocation of responsibility for public health. The goals of this Article are to identify legal challenges and potential solutions for expanding access to biomedical HIV prevention through health insurance coverage. This Article discusses the public policy implications of HIVprevention coverage decisions, assesses possible legal grounds on which insurers may initially deny coverage for these technologies, and evaluates the extent to which these denials may survive external and judicial review. Because several of these legal grounds may be persuasive, particularly denials on the basis of medical necessity, this Article also explores alternative strategies for financing biomedical HIV prevention efforts.

Condom use around the globe: how can we fulfil the prevention potential of male condoms?

Despite a global epidemic of sexually transmissible infections and the availability and endorsement of condoms as an effective intervention, the overall use of condoms remains low. This review explores various challenges and opportunities to fully realizing the prevention potential for condoms.