In what may possibly be one of the most potent moves to empower women in protecting themselves from getting infected with HIV, the Government is soon expected to make female condoms available under the social marketing programme.
With women accounting for more than one quarter of new HIV infections every year in India, the focus should be on protecting women. And the introduction of female condoms is a step in the right direction.
Though a report by the WHO last year showed nearly 15 per cent of the 5.1 million HIV infected in India as being commercial sex workers, there is still a huge population of commercial sex workers who are not infected.
Prevention holds the key
What the male condoms do to protect the male from getting infected or infecting his partner, the female condoms do for women. With prevention being the watchword, giving women a choice to protect themselves holds the key.
Though female condoms are already available in India, they are yet to become widely used. The hurdle is the price — Rs.100 apiece — and the target users being the commercial segment. The latest move is to subsidise it to make it available to commercial sex workers at Rs.5 in two months’ time. Female condoms are expensive compared with male condoms as they are manufactured by The Female Health Company based in the U.K., and are marketed by Hindustan Latex Limited.
An acceptability study done on sex workers in Thailand (Sexually Transmitted Diseases journal, 2001) found nearly two-thirds satisfied with female condoms.
A similar study done on sex workers in China and published in Contraception journal in 2002, found nearly 97 per cent of the sex workers showing interest in using female condoms once they were educated and the correct way of using female condoms was demonstrated to them.
A pilot study done in India in 2002 in Andhra Pradesh found 72 per cent of sex workers comfortable with female condoms.
“The results of the acceptability study undertaken in Maharashtra, Andhra Pradesh and Kerala one year ago are very encouraging,” said M. Ayyappan, Managing Director, Hindustan Latex Limited, Thiruvananthapuram.
Several studies have, however, pointed out the initial discomfort and difficulty that women face when using female condoms.
These handicaps are overcome with regular use though. `Acceptance and ease of application improved with use,’ noted the paper in the Sexually Transmitted Diseases journal.
Though heavily subsidised, the Rs.5 price tag may still appear expensive for some sex workers, which in turn may discourage them from buying a female condom despite its advantages.
“Strictly speaking, we should be supplying it free of cost for the first two years or so,” he noted. “We are making a recommendation to the Government for free distribution. This should go hand in hand with the subsidised female condoms.”
The acceptability studies have shown that female condoms will come to sex workers’ rescue when men refuse to use a condom but do not mind the sex workers using one. It is highly beneficial when some men in an inebriated state do not use a condom and fail to even realise that the woman is using one.
Question of reuse
Being more expensive compared with male condoms, it has been found that women tend to reuse female condoms several times. The polyurethane material used for making female condoms (unlike latex in the case of male condoms) makes reuse possible.
Though the WHO strongly recommends only single use of male or female condoms, wide prevalence of reuse has forced it to look at the issue more pragmatically. Accordingly, the WHO found that reuse up to seven times after disinfection with bleach and re-lubrication did not affect its structural integrity.
Though disinfecting with bleach (1:40 dilution of bleach in water for two minutes or 1:20 dilution for one minute) kills HIV and other disease causing organisms, the WHO makes it clear that it is not known if all potentially dangerous organisms get completely killed.
“We are not propagating the idea of reuse. We will project it as a disposable product after single use,” Mr. Ayyappan emphasised. “Reuse will actually do more harm than good (if not disinfected properly).”
It is to prevent reuse that the company and the Government are looking at the possibility of making it available free of cost to the segment of sex workers who can ill afford to dispose of it after single use.
“Reuse will no longer be an issue when the next generation female condom made from nitrile latex (synthetic latex) becomes available. The cost will come down by half,” he noted.
While reuse will be highly discouraged in the case of sex workers, those buying it from lifestyle stores will be counselled on reuse if they intend to do so.
Unlike male condoms, women intending to use female condoms need to be taught many things apart from being counselled and educated.
Support and some handholding will be particularly required in the initial stages in the absence of which studies have shown that women may stop using them. While commercial sex workers will stand to gain from the counselling and education on several aspects including the much-needed skills to negotiate with clients, the company plans to provide education and other support system for those buying it from lifestyle stores.
According to Mr. Ayyappan, the company intends to make female condoms available in 250 lifestyle stores where there will be some trained personnel to provide support and training to customers.
In a society where one feels embarrassed to even buy male condoms from a store, will the need to be demonstrated on the correct ways of using female condoms be a big deterrent?
Mr. Ayyappan does not think so. “The attitude (towards buying) is changing fast. Embarrassment while buying condoms is becoming less of an issue,” he explained. Only time will tell if his optimism is well founded.
At the end of the day, Mr. Ayyappan is sparing no efforts to ensure that the female condom does not get branded as something that only sex workers use. “Stigma will not be there if (everything is) done properly,” he said. “That is why we have (first) launched it for the commercial segment.”
While female condoms will go a long way in empowering women, men cannot altogether shift their responsibility on to women to curb the spread of infection.
The use of female condoms by women who are already HIV infected may not be high. The onus then lies with men to protect themselves. This underlines the necessity for one partner to always use a condom.