The fate of free male condoms distributed to the public in South Africa

The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models

Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.

A catastrophe in the 21st century: the public health situation in South Africa following HIV/AIDS

During the early 1900s, African populations in South Africa were subject to very widespread infections which especially affected the young. This resulted in high mortality rates and a low life expectancy of 20-25 years. By the mid-century, mortality rates from infections had decreased considerably. Moreover, the occurrences of non-communicable diseases, even in urban areas, remained very low. In the 1970s, the proportion of Africans aged 50 or over that reached 70 years was 38.5%, higher than that in the juxtaposed white population, which was 35.5%. And by 1985, the life expectancy of Africans reached 61 years for males and 63 years for females, probably the highest in sub-Saharan African populations. Since then, however, the African continent has been devastated by the AIDS epidemic. In 2001, HIV was responsible for the death of a third of the African population in South Africa, but even higher proportions prevailed in Botswana and in Tanzania. The calamitous advent of the HIV infection has caused major falls in life expectancy, in the case of Africans in South Africa reducing this to just 43 years. With little hope of meaningful changes occurring in sexual habits or of an early vaccine becoming available, the infectionís high morbidity/mortality burden is likely to continue.

Is cost a structural barrier preventing men who have sex with men accessing condoms? A systematic review

A systematic review was undertaken to determine whether cost is a structural barrier preventing men who have sex with men (MSM) accessing condoms. Studies were examined from a range of countries where condoms have been distributed free to particular populations and also those where condoms were available at a cost to the individual. The study inclusion criteria were: published between January 1990 and September 2014 inclusive; published in any language, discussed cost as a barrier to condom use, discussed cost barriers to MSM accessing condoms and included a measure of outcome. Articles were systematically extracted from MEDLINE, Embase, PyschINFO and Informat using the five search terms; Male Homosexuality, Access, Cost, Cost and Cost analysis, Condoms. Sixty-four articles were initially identified and 11 included in the final review. The included studies used cost-utility analysis, qualitative, cross-sectional, cohort or randomised control trial design. Large-scale free distribution programmes and smaller targeted programmes showed positive correlations in reducing the burden of disease from HIV and other sexually transmitted infections through eliminating the issue of cost. Decreasing the cost of condoms, and providing them for no cost, appears to increase their utilisation amongst MSM and possibly reduce the burden from HIV and other sexually transmitted infections. Inequality and stigma remain important barriers to MSM accessing and using condoms particularly in the developing world.

Progress and challenges to male and female condom use in South Africa

South Africa has responded to the sexually transmissible infection and HIV epidemic with a rapid expansion of its national-level public sector condom program. Male condoms are available widely at no cost in the public sector, with expanded access via social marketing and the private sector. The female condom program is one of the largest and best established globally. National surveys show progressive increases in rates of condom use at last sex. However, inconsistent and incorrect condom use and the likelihood that condoms are discontinued in longer-term partnerships are some of the challenges impeding the condom program's successes in the fight against sexually transmissible infections and HIV. This article reviews the current condom program, related guidelines and policies, and the existing data on male and female condom use, including distribution and uptake. We discuss the main challenges to condom use, including both user and service-related issues and finally how these challenges could be addressed.

Correlates of male condom use skills among high-risk women in South Africa

This exploratory study examined the performance of 295 South African women--who recently traded sex for goods or had unprotected sex--on a male condom use mastery index. Bivariate and multivariate logistic regression analyses were conducted to determine whether age, marital status, highest education obtained, male condom use at first penetrative sex, receiving prior demonstration of male condom use, recent sexually transmitted infection symptoms, and recently trading sex were significantly associated with index scores. Adjusted odds ratios indicated that age and sexually transmitted infection symptoms were negatively associated with condom skills; women who were older and had a higher number of recent sexually transmitted infection symptoms were more likely to have lower scores. Furthermore, participants executed, on average, approximately one third of condom use steps correctly. These findings suggest a need for increased behavioral skills training for women engaging in sexual risk behaviors because many lack the skills required to use a male condom properly.

The effects of condom choice on self-reported condom use among men in Ghana, Kenya and South Africa: a randomized trial

BACKGROUND

Male condoms are readily available and affordable in many settings, but risky sexual acts still go unprotected.

STUDY DESIGN

This unblinded randomized trial, conducted in Ghana, Kenya and South Africa, was designed to assess the impact of providing a choice of condoms on self-reported use and uptake over 6 months.

RESULTS

We enrolled 1,274 men. The mean subject-specific proportion of protected acts with all partners increased from baseline to 6 months by 0.07 in the control group compared to 0.03 in the choice group (p=.025). The observed results were largely consistent across all three countries. In the choice group, men clearly preferred one condom type over the others, and this preference was consistent across all three countries.

CONCLUSIONS

Providing one type of male condom in public sector programs appears justified. Programs should not focus on the number of brands available, but should encourage effective promotion and consistent and correct use of available brands.

Condom access in South African schools: law, policy, and practice

Juliana Han and Michael L. Bennish discuss their experience developing a policy on condom distribution for Mpilonhle, a South African nongovernmental organization involved in HIV prevention in schools.

Patterns of condom acquisition and its association with consistent use among young men in Nigeria

There is limited information about the influence of condom acquisition patterns on consistent condom use. Research is required to identify the relative extent of consistent condom use among individuals who always obtain condoms free, or who always have mixed procurement of free and purchased condoms or who always purchase condoms. The study analysed condom acquisition and sexual behaviour practices of 372 young men and logistic regression was analysed to determine whether condom acquisition practice was a predictor of consistent condom use. Results showed that most participants (41%) had mixed procurement of free and purchased condoms, 31% always bought condoms while 28% always purchased condoms. Majority of individuals (71%) who always purchased condoms, 23% who had mixed procurement, and 12% who had free condoms consistently used condoms. The results also showed that having 2 or more partners and always purchasing condoms increased the likelihood of consistent condom use. It is recommended that programmes of free condom supply should also incorporate in it education that emphasizes consistent condom use with a partner whose HIV sero status is not known.

Utilization of a basic care and prevention package by HIV-infected persons in Uganda

Opportunistic infections are the leading cause of mortality among HIV-infected people. Several simple interventions prevent illness, prolong life, or prevent HIV transmission from HIV-infected people in Africa. These include: cotrimoxazole prophylaxis; insecticide-treated bed nets; supplies for household water treatment and safe storage; materials promoting family voluntary counselling and testing (VCT); and condoms. We provided these interventions to adults and children with HIV who were members of the AIDS Support Organization in Uganda. To evaluate use of this basic care and prevention package, we surveyed a representative sample of 112 clients of TASO in their homes. Among respondents, 95% reported taking cotrimoxazole everyday, 89% said they had slept under a bednet the night before, 65% reported current treatment of household drinking water, 89% of sexually active respondents reported using condoms, and 96% reported family use of VCT. Household observations verified that use of cotrimoxazole, bednets, and water treatment products were consistent with reported use. This evaluation suggests successful distribution and use of basic care and prevention services at an AIDS organization in Uganda.

Condom social marketing, Pentecostalism, and structural adjustment in Mozambique: a clash of AIDS prevention messages

Despite significant debate about the efficacy, ideology, and ethics of the method, condom social marketing (CSM) has become the dominant approach to AIDS education in many sub-Saharan African countries. However, critics have charged that social marketing (SM) distracts from the structural determinants of health-related behavior and excludes genuine community participation. This article argues that the diffusion of SM techniques in Africa is not driven by demonstrated efficacy but is attributable to the promotion of privatization and free markets in the structural adjustment era across the region. The CSM experience in a central Mozambican community reveals the dangers of using the method at the expense of community dialogue and participation to confront the AIDS epidemic. The advertising campaign developed to sell condoms has clashed with Pentecostal and Independent Churches, now a majority of the population, that have expanded rapidly across the region spreading a contrasting message about sexuality and risky behavior.

Improving the accessibility of condoms in South Africa: the role of informal distribution

Lack of access to condoms presents a fundamental barrier to HIV prevention across most of sub-Saharan Africa. One strategy to enhance the accessibility of condoms is to promote their informal distribution outside of health facilities through existing social networks. To investigate the prevalence and practices of informal condom distribution, we administered a questionnaire to individuals procuring condoms at 12 public health facilities in four regions of South Africa. Of the 554 individuals interviewed, 269 (48%) reported either giving or receiving condoms informally in the month before the study. In multivariate analysis, reporting informal condom distribution was associated with increased education, male gender, multiple sex partners and recent condom use. The specific practices involved in giving or receiving condoms differed between males and females, with women more likely to involve family members and men more likely to involve friends. These results indicate that informal condom distribution is surprisingly common among individuals procuring public sector condoms in South Africa, and begin to suggest the gendered nature of informal condom distribution networks. While these findings require confirmation in other populations, the practices of informal condom distribution described here provide an excellent opportunity for enhancing condom accessibility and delivering other interventions for HIV prevention.

Condom use and sexual behaviors among individuals procuring free male condoms in South Africa: a prospective study

BACKGROUND

Although the South African government has increased the number of male condoms distributed free to the public, there is no understanding of whether these are being used effectively to prevent the spread of sexually transmitted diseases, including HIV infection.

GOAL

The study goal was to determine sexual behaviors and barriers to condom use among individuals procuring condoms distributed free to the public sector.

STUDY DESIGN

In a prospective study, individuals who procured condoms from 12 public health facilities across South Africa were recruited and observed for the next 5 weeks.

RESULTS

The 384 successfully observed subjects reported 3262 sexual contacts, of which 2637 (81%) involved protection with a condom. In multivariate analysis, alcohol consumption and use of other contraceptives were associated with unprotected sexual intercourse.

CONCLUSION

The levels of condom use are relatively high in this population, but these data highlight several important barriers to condom use that may be targeted by future interventions.

The epidemiology of human immunodeficiency virus in South Africa

We review the epidemiology of human immunodeficiency virus (HIV) in South Africa where the prevalence of HIV infection is among the highest in the world. The epidemic reached South Africa relatively recently but the prevalence of infection has increased rapidly and there are significant differences among provinces. Although few 15-year-old people are infected the prevalence increases rapidly with age thereafter, especially among women. The prevalence of herpes simplex virus type 2 exceeds that of HIV and curable sexually transmitted infections are common. 'Circular migration' may help to explain the high rates and rapid spread of HIV in the region. The incidence of tuberculosis has increased dramatically as a result of the HIV epidemic. Antiretroviral therapy for the prevention of vertical transmission has been shown to be effective in local conditions but transmission through breast-feeding remains problematical. While some epidemiological models have been developed, much more needs to be done in this regard in order to plan, coordinate and evaluate an effective response to the epidemic. We conclude by discussing some of the research that is needed and steps that could be taken to reduce the continued spread of the infection.