A nationally representative survey of healthcare provider counselling and provision of the female condom in South Africa and Zimbabwe

Lessons from the evaluation of the South African National Female Condom Programme

BACKGROUND

Understanding of the facilitators and challenges to female condom (FC) uptake has been limited due to lack of evaluation of national FC programmes.

SETTING

The FC has been an integral component of South Africa's (SA) HIV prevention programme for 20 years and is the largest government-funded FC programme worldwide.

METHODS

The national FC evaluation used a mixed-methods approach and consisted of key informant interviews and a telephone survey in a national sample of public and non-public sites. A sub-sample of sites participated in client and provider interviews, and a self-administered client survey. A review of distribution statistics from South Africa's District Health Information System was also conducted.

RESULTS

All 256 public-sector and 28 non-public-sector facilities reported having ever distributed FCs. Less than 5% of these facilities reported stock-outs and less than 3% reported they had a supply of expired female condoms. Systems for male condom (MC) and FC distribution were complementary, with similar ordering, delivery and reporting processes. FC promotion by providers (n = 278) varied with regard to FC training, whether attitudes about FCs influenced providers offer of FCs, and how they counselled clients about FCs. Of the 4442 self-administered client surveys in 133 facilities, similar proportions of women (15.4%) and men (15.2%) had ever used FCs. Although FCs were available at almost all sites surveyed, only two-thirds of clients were aware of their availability.

CONCLUSION

Data highlight the role of providers as gatekeepers to FC access in public and non-public sectors and provide support for further FC programme expansion in SA and globally.

Perceived confidence to use female condoms among students in Tertiary Institutions of a Metropolitan City, Southwestern, Nigeria

BACKGROUND

Latex condoms for men have been documented to offer high efficacy as both a contraceptive and protection against sexually transmitted diseases. This equally establishes the importance of continued research on female condoms. This study aims to investigate the perceived confidence to use the female condoms amongst undergraduate female students from selected tertiary institutions from Ibadan Southwestern Nigeria.

METHODS

The study was a descriptive cross-sectional survey involving 388 female undergraduate students selected through a multistage sampling technique. The survey was carried using pre-tested semi-structured questionnaires. Quantitative data were analyzed using the Statistical Package for the Social Sciences to generate frequencies, cross tabulations of variables at 5% level of significance.

RESULTS

Mean age of respondents 18.26 ± 3.45 with most students being 20-24 years (55.2%), single (92.8%), Yorubas (85.6%) and from the polytechnic institutions (41.0%). Only 10.8% had good perceived confidence to use a female condom. Perceived confidence was significantly higher amongst other ethnicities (19.59 ± 3.827) compared to Yoruba ethnicity (18.04 ± 3.337) (F = 9.935; p < 0.05). Likewise, students from the Polytechnic campuses exhibited significantly higher mean scores (18.81 ± 3.187) compared to others (F = 3.724; p < 0.05). Perception towards the condom was a significant factor that influenced the confidence to use a female condom (F = 9.896; p < 0.000).

CONCLUSIONS

Concerted efforts are advocated to improve the low perception exhibited towards the use of female condoms and the low perceived confidence to its utilization. This would help to transfer the decision making and control to women thus contributing to their empowerment and increased protection from unplanned pregnancies and sexually transmitted diseases.

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.

Clinicians' perceptions and provision of hormonal contraceptives for HIV-positive and at-risk women in Southern Africa: an original research article

OBJECTIVES

To assess clinician provision of hormonal contraception for HIV-positive and at-risk women in Southern Africa.

STUDY DESIGN

We conducted a nationally representative survey of clinicians (n=1444) in HIV-prevalent settings in South Africa and Zimbabwe to evaluate evidence-based contraceptive care and clinician views of hormonal contraceptives for HIV-positive and at-risk women. Multivariable logistic regression was used to analyze differences in contraceptive provision by professional training and practice setting.

RESULTS

Most providers offered oral contraceptives (85%), but only a small minority considered them appropriate for women at risk of HIV (27%) or HIV-positive women (25%). A higher proportion of clinicians considered injections appropriate for women at risk of HIV (42%) or HIV-positive women (46%). Very few considered emergency contraceptives appropriate (13%). Multivariable results showed that family planning training and clinic as compared to hospital practices were associated with evidence-based attitudes about contraception for HIV-positive or at-risk women and greater provision. There were no differences, however, between physicians and nurses or by HIV training.

CONCLUSIONS

These findings emphasize the need to improve clinicians' awareness of evidence-based guidelines for hormonal contraception for women at high risk of HIV and HIV-positive women. Evidence-based information that oral contraception and injections are appropriate is essential. Contraceptive education should be integrated into HIV training to reach at-risk populations.

How much demand for New HIV prevention technologies can we really expect? Results from a discrete choice experiment in South Africa

Background

For the first time in the history of HIV, new bio-medical interventions have been shown to be effective in preventing HIV transmission. For these new HIV prevention technologies (NPTs) to have an impact on the epidemic, they must be widely used. This study uses a discrete choice experiment (DCE) to: understand the relative strength of women’s preferences for product characteristics, understand the implications for substitution away from male condoms, and inform realistic modelling of their potential impact and cost-effectiveness.

Methods

A DCE was conducted among 1017 women in urban South Africa. Women were presented with choices between potential women’s NPTs (microbicides, diaphragm, female condom) and ‘what I did last time’ (use or not use a condom) with different HIV and pregnancy prevention effectiveness’ and prices. Choice probabilities are estimated using the nested logit model and used to predict uptake.

Results

In this high HIV prevalence setting, HIV prevention effectiveness is the main driver of uptake followed by pregnancy prevention effectiveness. For example a microbicide with poor effectiveness would have niche appeal at just 11% predicted uptake, while a highly effective microbicide (95% effective against HIV and pregnancy) would have far wider appeal (56% predicted uptake). Though women who reported not using condoms were more likely to choose the NPTs, at current very high rates of male condom use in South Africa (60%), about half of microbicide uptake is projected to be among those currently not using condoms.

Conclusions

Women are very interested in NPTs, especially if highly effective in preventing HIV and pregnancy. Women in greatest need were also most likely to switch to the new products. Where products are not yet available for distribution, proxy data, such as that generated by DCEs, can bring realism to overly optimistic uptake scenarios found in many current impact models.