Long seen as the ugly step-child of HIV prevention, the female condom seems to be gaining popularity through grassroots campaigns, according to a report by the UN Population Fund (UNFPA).
"For the fourth consecutive year, access to female condoms has increased dramatically, reaching a record number of 50 million... in 2009," the report states.
The female condom is a 17cm-long polyurethane sheath with a flexible ring at each end. It provides about the same protection from sexually transmitted infections - including HIV - and unwanted pregnancy as the male condom, but unlike the male condom, can be used with oil- and water-based lubricants without the risk of breakage.
The organization credits successful partnerships between governments and technical agencies for helping to increase access to female condoms. In 2005, UNFPA launched the Female Condom Initiative in 24 countries to ensure that female condom programming was integral to national AIDS policies and reproductive health programmes.
Creative approaches
"In a number of countries, governments... are applying highly creative approaches to educating the public about condoms and to overcoming the stigma and taboos sometimes associated with them," the report's authors said. "In the process, they are discovering that the female condom is a tool for women's empowerment, enabling women and adolescent girls to take the initiative to protect their own and their partners' health."
In Zimbabwe, billboards, radio spots and TV adverts helped boost female condom distribution by the public sector from about 400,000 in 2005 to more than two million in 2008, while the sales of female condoms went up from 900,000 in 2005 to more than three million in 2008.
Programmers in Zimbabwe used hairdressers to market the female condom, which proved highly successful.
"Often the hairdresser will work from a chair in her back yard. Such improvised salons stay open at all hours, so women can have their hair done � and discuss personal matters � in privacy," the authors reported.
UNFPA's partner, Population Services International (PSI), provides day-long training workshops around the country for the 2,000 hairdressers and 70 barbers who act as sales representatives for the female condom. PSI also employs 20 female condom promoters who distribute the condoms to hairdressers and barbers and spread the word about the training.
This approach was also used successfully in Guyana and Malawi.
In Ethiopia, the programme used coffee ceremonies, an age-old social custom, to reach married women. Because condoms - perceived to be used by promiscuous people and sex workers - are highly stigmatised in Ethiopian society, programmers highlighted the family planning benefits of the female condom.
In Myanmar, efforts targeted high-risk female sex workers and men who have sex with men, with PSI rebranding the condoms "Feel for Men" to make them more appealing to MSM.
Although not recommended for anal sex by the UN World Health Organization, some health authorities [ http://www.ebar.com/news/article.php?sec=news&article=5465 ] have opted to market it for use by MSM. In a 2002 US study [ http://www.ncbi.nlm.nih.gov/pubmed/12646796 ], men reported more frequent problems with female condoms than male latex condoms, particularly slippage, discomfort and rectal bleeding; the authors recommended more research on the safety of female condoms for anal sex.
Lagging behind the male condom
Despite these gains, the female condom still lags behind the male condom in popularity; according to UNFPA, more than 10 billion male condoms are used every year globally.
In Kenya, female condoms are part of the country's broader HIV and family planning programmes, but women have shown little interest. The country recently received three million female condoms from UNFPA and distributed them.
"We do not have reliable data on acceptability but we know that among sex workers there is a high demand," said Peter Cherutich, head of HIV prevention at the National AIDS and Sexually transmitted infections Control Programme. "Overall, the demand is low mainly due to general unavailability and [lack of] information.
"It is still more expensive [than the male condom] and we are yet to be confident that it is as widely popular as the male condom," he added. "Except for female sex workers and highly empowered women, most other women do not have the capacity to demand safe sex... the majority of women depend on their sexual partners to protect them."
The UNFPA report noted that female condoms can cost as much as US$1 each while male condoms are often distributed free of charge. In pharmacies in Nairobi, a pack of three male condoms costs just over $1.
Challenges
"In 2009, only one female condom was available for every 36 women worldwide," the report states.
One of the major complaints women had about the original FC1 female condom was that it was noisy [ http://www.plusnews.org/report.aspx?reportid=72690 ] during sex. The newer FC2 female condom is quieter [ http://www.plusnews.org/report.aspx?reportid=87526 ] and less expensive to produce but many women still feel it is more complicated than the male condom.
"We are trying to popularize it among sex workers, but they say if you have five or 10 customers in one night, the male condom is more convenient - with the female condom, it takes time to put on, then it has to warm up to your body temperature and the guy knows it's there," said Macklean Kyomya, executive director of the Ugandan NGO, Women's Organization Network for Human Rights Advocacy, which represents sex workers.
Lillian Mwamba, who lives in Nairobi, says she would use the female condom more often if it were more widely available.
"I have used a female condom on certain occasions but my partner and I prefer the male one because they are easy to come by and you can walk into any shop, even a kiosk, and get it; female condoms are very rare and expensive," she told IRIN/PlusNews. "But on the occasions I have used it, I can't say it was bad - it gives me as a woman some control."
Ignorance persists
Conversations with other Nairobians reveal that ignorance about the female condom is still widespread. "From the demonstrations I have seen, the female condom is inserted inside and your penis too goes inside. Now I am thinking to myself, what if I push it deeper inside and the woman gets hurt?" said Paul Mayaka. "And where do you get it even if you wanted your woman to have it?"
Mayaka added that he couldn't "trust my life with something that is washed like a cloth", referring to the practice of washing the female condom for reuse, which is not recommended by the UN World Health Organization.
NASCOP's Cherutich said the Kenyan government would need to market the female condom in new ways to increase use. "We have not placed the female condom as a family planning tool, which if we had, would make FC less stigmatizing since family planning is now an accepted concept within family settings," he said.