Sexual transmission of HIV

UNAIDS Executive Director Michel Sidibé (left) met with M.R. Sukhumbhand Paribatra, Governor of Bangkok, on 16 February at the Bangkok Metropolitan Administration City Hall. Credit: UNAIDS/V. Dithajohn

In an official mission this week to Thailand, UNAIDS Executive Director Michel Sidibé held discussions with M.R. Sukhumbhand Paribatra, Governor of Bangkok, on progress, challenges and opportunities for the AIDS response in the Thai capital. During the meeting, Mr Sidibé asked for increased support to help make Bangkok the first city to reach the goal of "zero new HIV infections."

Acknowledging the specific challenges faced by mega-cities in Asia—where new HIV infection rates among some key populations, including men who have sex with men, remain high and where migration is a complex daily reality—Mr Sidibé urged the Governor to play an active role in the June 2011 UN General Assembly High-Level Meeting on AIDS with other high-level city officials from mega-cities around the world. "This would be a perfect opportunity to tell the world that Bangkok is committed to getting to zero," said Mr Sidibé.

In his discussions with Mr Sidibé, Governor Paribatra said that a focus on marginalized populations, particularly migrants, is critical to effective AIDS responses in Bangkok. While underscoring the complexity of city-based approaches to the HIV epidemic, he stressed his intention to rise to the challenge of "zero new HIV infections" in the Thai capital. Governor Paribatra expressed interest in attending the High-Level Meeting in June and in addition hosting a "getting to zero" gathering of officials from other mega-cities in the region during his term.

This is the third of five animated films for the social media initiative “HIV #PreventionRevolution”, that UNAIDS is running in the lead up to World AIDS Day 2010.

The aim is to inspire and encourage people using social media to know more about HIV prevention. The collective goal is to make the hashtag #PreventionRevolution shared as much as possible on 1 December 2010.

For the past two weeks, conversations have focused on why an HIV prevention revolution is needed and condom programming, under key messages such as “80% of HIV transmission is sexual” and “More than 7 000 people are infected with HIV everyday”.

It has connected tweeters such as @UN, @MTVStayingAlive, @Oxfam and @AnnieLennox. 

Most importantly the conversation has engaged twitter users from all walks of life; all tweeting about the Prevention Revolution at the same time across at least five continents!

People on twitter have shared personal stories, called out for action on local level and the tweets seem to be sharing information that users did not previously have. For example:

@LoganLevkoff, tweeted: “Unacceptable,” in reply to the fact that only 1 in 3 young people have knowledge of how HIV is transmitted.

@0newinfections, a person on twitter living with HIV who uses twitter, urged his followers to join the conversation:  

“I often wonder how long will i live. I became HIV positive when i was 25. Maybe 10 years more or 20? Be a part of the #PreventionRevolution”

Users have also come up with a new word on twitter “Edutweeting,” made from Education and Tweeting for what the initiative is trying to achieve.

This week’s discussion starter is the animated film Light, embedded above. Follow the conversation on twitter here and by visiting UNAIDS on Facebook.

A version of this story first appeared at www.unfpa.org 

The UNFPA-sponsored football tournament offered a way to get the attention of young people in northern Uganda. Photo: Stijn Aelbers/UNFPA Uganda

Although hostilities in northern Uganda ceased in 2006, the lives of young people, formerly targets for abduction by the Lord’s Resistance Army, have not been easy. During the conflict, which lasted more than 20 years, many children spent their early years confined to camps for displaced persons, while others were subjected to trauma, brutality and suffering as child soldiers.

Prolonged instability also took a toll on health and social support systems: reproductive health indicators in the sub-region are among the lowest in the country, and gender-based violence is common.

While the majority of youth—who comprise 56 % of Uganda’s population—live in poverty with few educational or employment opportunities, football is one thing that they can get excited about and that allows them to forget about their troubles. Florence, age 23, from a squad in Gulu District said, “If we come to play football we forget our problems at home. It is like stress management.”

At the Acholi Football Tournament, which took place in five districts, and was supported by UNFPA, the United Nations Population Fund, the goal was to do more than more than help young people relax. It also aimed to reduce teenage pregnancy and gender-based violence, two of the most serious problems in the area.

Referees, coaches, and team captains attended training sessions on the issues, and then became a resource for information, discussion, and guidance. Subsequent dialogue sessions reached some 1,200 players.

Top local officials awarded the winning teams with uniforms that read, “Say no to GBV (gender-based violence) and teenage pregnancy.” Health care workers were also on hand to answer questions and provide health counseling. Over the course of two days, some 10,000 condoms, most supplied by UNFPA, were distributed by health workers and peer counsellors as well as representatives of the Boda Boda Association, which employs many young men as motorcycle taxis drivers.

More than 800 individuals, mostly young men, took advantage of the free voluntary testing and counselling that was offered to allow them to check their HIV status.

Women were also on the pitch, although many are less experienced than their male counterparts, spectators say the buzz of the women’s matches created were a demonstration of the growing popularity and re-thinking of gender roles

A player from the Lalogi team said she has encountered negative attitudes. (See how these are addressed in a new electronic football game.) However, 21-year-old Rose said her husband was supportive: “He is happy that I play. I think he is here watching today,” she shouted over her shoulder as she ran onto the pitch for kick-off.           

H.E. Ismail Omar Guelleh, President of the Republic of Djibouti together with Mr Michel Sidibé, UNAIDS Executive Director. Credit: UNAIDS/P.Virot

Each year, there are more than 200 million people on the move. The UN estimates that between 20 and 30 million are migrants in irregular situations and that wars and conflicts have caused the displacement of 16 million refugees. 

Many countries around the Red Sea and Gulf of Aden are affected by intense poverty and violent internal conflicts. This has resulted in large numbers of migrants living in and around the ports. There is also a large community of mobile populations, including truck drivers, dock workers, port staff, security staff, ships crews and sex workers who can be at higher risk of exposure to HIV.

Poverty, social exclusion; separation from families and communities, loneliness, fear and marginalization can make mobile populations and migrants particularly vulnerable to HIV. The situation can also be aggravated by lack of access to HIV prevention, treatment and care services.

“It is essential that mobile and migrant populations living in and transiting through ports have access to HIV services and are included in national HIV plans,” said Michel Sidibé, Executive Director, of the Joint United Nations Programme on HIV/AIDS (UNAIDS). “Achieving universal access goals means making sure all sectors of society are reached, particularly people most vulnerable to infection.”

The Government of Djibouti, in close collaboration with UNAIDS, the International Organization of Migration, the Inter-Governmental Authority on Development (IGAD), and other partners, convened a meeting from 26-29 September 2010, which brought together leaders from Red Sea countries and other countries across Africa to address the issue of key populations at higher risk of HIV infection along the Red Sea and the Gulf of Aden ports.

“For us, this conference has been extremely instructive, we have learnt a lot from the experts, but particularly from people living with HIV who have come forward to tell us their stories,” said His Excellency Abdallah Abdillihi Miguel, Minister of Health of Djibouti. “This meeting has reinforced my conviction that we have to continue to work towards universal access to HIV prevention, treatment, care and support and make sure that everyone in need, even those most marginalised and vulnerable, has access to services.”

The experts and leaders agreed to take concrete actions to strengthen advocacy and leadership on HIV and mobility; integrate HIV and mobility into national strategic plans; ensure improved planning; enhance the capacity of civil society and partnerships with the private sector; and develop a common communication strategy with particular emphasis on human rights.

Dr Peter Ghys, Chief of Epidemiology and Analysis Division UNAIDS, presented the findings of the new analysis together with the Vienna Youth Force at the International AIDS Conference. Credit: UNAIDS/Anne Rauchenberger

A change is happening among young people across the world, especially in parts of sub-Saharan Africa. Young people are waiting longer to become sexually active, have fewer multiple partners and are increasingly using condoms among those with multiple partners. As a result, HIV prevalence among young people is dropping in many key countries according to a new analysis by UNAIDS.

Dr Peter Ghys, Chief of Epidemiology and Analysis Division UNAIDS, presented these findings together with the Vienna Youth Force today at the International AIDS Conference.

The study shows that HIV prevalence trends in 16 countries is declining among young people aged 15–24, and according to the study declines are largely due to falling new HIV infections among young people. In 15 out of 21 countries most affected by HIV in the world, a decline of 25% has been noted.

According to Dr Ghys, the results show a good concordance between trend in sexual behaviour and trends in HIV prevalence.

“UNAIDS calls on countries to implement comprehensive set of programmes to reduce the risk of young people; and young people themselves can and must be actors in these changes,” said Dr Ghys.

Young people engaged in the AIDS response in countries which are experiencing this decline were invited to comment on the new findings.

Kuena Diaho, the World Young Women’s Christian Association Lesotho, said that programmes targeting young people need to be shaped in a way so that they are not too heavy. “In Lesotho, we do edutainment; HIV prevention activates through poetry and sport.  This way, it’s a little less heavy,” said Diaho.

“We’re a large network of young women’s organizations. We use facebook to share information, and we organize gatherings to talk about sexual and reproductive health education,” said Yvonne Akotho from the Girl scouts in Kenya.

Remmy Shawa, UNAIDS special youth fellow, from Zambia stressed that this new evidence should be used as an advocacy tool to show leaders what happens when young people are placed at the centre of the AIDS response.

Dr Ghys concluded the session noting that these encouraging results are an early return on investments made in HIV prevention. “These investments need to continue and programmes with and for young people need to be scaled up,” said Dr Ghys.

As the 2010 World Cup kicks off this Friday, thousands of football fans will arrive in South Africa to cheer on their favourite teams.

HIV awareness and prevention is also a high priority during this time. HIV can spread particularly among young people, through the dangerous combination of alcohol and unsafe sex.

As HIV can be spread through unprotected sex, condoms are vital to protecting people from HIV infection. Male and female condoms are the most efficient, available technologies to reduce the sexual transmission of HIV and other sexually transmitted infections.

And to reduce the risk of HIV transmission, advocates count on making condoms readily available. Previously successful campaigns have included free condoms in match venues, hotels, stadiums, bars, and clubs. As one fan said, “condoms are more useful with me than in a warehouse.”

Condoms are a key component of the combination prevention package to reduce the sexual transmission of HIV. Other components include delay of sexual initiation, abstinence, being mutually faithful to each other when both partners are uninfected, and reducing the number of sexual partners.

UNAIDS commends the South African government’s commitment to distribute condoms during the World Cup. We support the efforts carried out by the South African National AIDS Council (SANAC) and civil society groups, including the Treatment Action Campaign and AIDS Consortium, to ensure that condoms and HIV information are made widely available during the tournament.

Each day, 7 400 people are infected with HIV worldwide. In South Africa, the host of this year’s World Cup, 5.7 million people are living with HIV ─ the largest number worldwide.

New data analysis released on 10 March by the United States Centers for Disease Control and Prevention (CDC) highlights that HIV and syphilis disproportionately impact men who have sex with men in the United States (U.S.).

New data analysis released on 10 March by the United States Centers for Disease Control and Prevention (CDC) highlights that HIV and syphilis disproportionately impact men who have sex with men in the United States (U.S.).
The data, presented at CDC's 2010 National STD Prevention Conference, found that the rate of new HIV diagnoses among men who have sex with men (MSM) in the U.S. is more than 44 times that of other men and more than 40 times that of women.

"While the heavy toll of HIV and syphilis among gay and bisexual men has been long recognized, this analysis shows just how stark the health disparities are between this and other populations," said Kevin Fenton, M.D., Director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. "It is clear that we will not be able to stop the U.S. HIV epidemic until every affected community, along with health officials nationwide, prioritize the needs of gay and bisexual men with HIV prevention efforts."

According to CDC many aspects contribute to the high rates of HIV and syphilis among gay and bisexual men in this country. Homophobia and stigma can prevent MSM from seeking prevention, HIV testing and counselling, and treatment services. Other causes include limited access to prevention services, unsafe sex practices and complacency about HIV risk due to existence of treatment, particularly among young gay and bisexual men.  Also, the risk of HIV transmission through anal sex is much greater than the risk of transmission via other sexual activities.

''It seems like we have come full circle in the United States,'' said UNAIDS Executive Director Michel Sidibé. ''Efforts must be redoubled to include gay and bisexual men in AIDS programming and reach out to and address the HIV prevention needs of all men who have sex with men.'' 
Prevention programmes

According to UNAIDS, HIV prevention measures for men who have sex with men should include consistent and proper use of condoms, and access to water-based lubricants. High quality HIV-related services, like voluntary counseling and testing in a non-discriminatory environment,, should be made available as well as specific and targeted information on prevention and risk reduction strategies designed to appeal to and meet the needs of men who have sex with men. Further quality treatment for sexually transmitted infections with referral for HIV services must be made available.

The U.S. Department of Health and Human Services notes that in the United States men as a whole, are less likely to use the health care system than women. Men often seek care when they are experiencing critical health problems. Men who have sex with men who do not access health care may not know they are infected with HIV or an STD, thus compromising their own health status. The persistence of stigma and homophobia compounds the situation still further.

CDC officials noted that the new analysis underscores the importance of the HIV and STD prevention efforts to reach gay and bisexual men recently announced as part of the U.S. President's fiscal year 2011 national budget proposal.

The new analysis is the first step in more fully assessing the extent of HIV among MSM and other populations in the United States. The CDC is developing more detailed estimates of infection rates among MSM by race and age, as well as among injection drug users. Ultimately, these data can be used to better inform national and local approaches to HIV and STD prevention to ensure that efforts are reaching the populations in greatest need.

A version of this story was first published at www.undp.org

Community conversations have proven to be an effective way to combat HIV in Namibia.
Credit: UNDP Namibia

What causes people to have more than one sexual partner at a time? “Sexual desire and satisfaction”; “It’s a cultural and social norm”; “Poverty and hunger; it’s a way to survive.” These are just some of the perspectives that emerged when communities under four traditional authorities came together to talk about what is known as ‘multiple and concurrent partnerships’ in the Caprivi region, in North East Namibia. This region is the most affected by the HIV epidemic in the country, where one in three pregnant women were found to be living with HIV in 2008.

The community conversations held late in 2009 is one of many taking place in throughout the country as part of a nationwide programme that engages communities in dialogue on the causes of HIV, boosting local responses to the epidemic.

The programme is known as ‘Community Capacity Enhancement through Community Conversations’. It is being implemented by the Namibian Ministry of Regional and Local Government, Housing and Rural development, with the support of the United Nations Development Programme (UNDP) in Namibia.

Multiple and concurrent partnerships have been identified as one of the main reasons why HIV has spread so rapidly in Namibia. “Long ago, marriages were respected. Nowadays, we have left this culture behind and both men and women have multiple sexual partners”, said one participant.

“By bringing together men, women and all those affected by HIV, this approach gives people the opportunity to make their voices heard, to identify their needs and to be counted when decisions about AIDS interventions are made,” says the Manager of UNDP’s Community Capacity Enhancement Programme, Immanuel Mwilima.

Community Capacity Enhancement through Community Conversations is a tried and tested methodology to boost the capacity of communities to identify concerns, deliberate on solutions and map out courses of action around AIDS.

Community members working with condoms during a community conversation on MCP in Katima Mulilo, Caprivi region.
Credit: UNDP Namibia

The approach opens up spaces for discussions based on relationships of trust and mutual respect.

According to Mr Henk Van Renterghem, UNAIDS Country Coordinator in Namibia, the community conversations offer a unique opportunity to strengthen the capacity of communities to engage with local government and development partners on the allocation of resources in the AIDS response.

“Too often communities are considered to be the passive recipients or beneficiaries interventions. They are inadequately consulted in top down processes for the identification of needs and priorities,” said Mr van Renterghem.

To date, communities in nine regions are conducting community conversations, with impressive results. In Caprivi, traditional leaders have led by example, going for voluntary counselling and testing and tackling the stigma associated with testing. In the words of one leader: “It is shocking that many of our relatives and loved ones have died because of AIDS....If this programme had come sooner, our relatives would have been alive today.”

Many challenges still remain in the AIDS response, however. For instance, 17.8% of pregnant women are HIV-positive in Namibia. “One of the biggest challenges facing rural communities in relation to accessing treatment, care and support services is stigma, discrimination, cultural norms and practices. Community Capacity Enhancement gives communities an opportunity to have an introspection of their cultural practices, norms and values,” says Lebogang Motlana, the Deputy Resident Representative of UNDP in Namibia. While the country is among the five most affected by HIV around the world, the epidemic is now on a downward trend, at just over 15%, after peaking at 22% in 2002.

(from left): UNIFEM Regional Director East and South East Asia, Dr Jean D’Cunha; UNAIDS Director of the Asia Pacific Regional Support Team, Prasada Rao; Executive Director of the ASEAN Foundation, Filemon Uriarthe Jr; and APN+ Regional Coordinator and Director, Shiba Phurailatmam.
Credit: UNAIDS

Studies in Asia indicate that most women in the region acquire HIV because of their partners who engage in unsafe behaviours. It is estimated that more than 90% of women living with HIV acquired the virus from their husbands or boyfriends while in long-term relationships. An effective AIDS response must address intimate partner relationships to prevent HIV infections in the female partners of men with high-risk behaviours.

In an effort to fill this gap in the AIDS response, UNAIDS and the ASEAN Foundation signed an agreement in Bangkok to support work on gender and HIV in the Asia Pacific region.

The partnership began in 2007 when the United Nations Development Fund for Women (UNIFEM) and UNAIDS joined hands with the ASEAN Foundation in order to strengthen joint work on the gender aspects of HIV.

In 2008 the partnership expanded to include the United Nations Development Programme (UNDP); the Asia Pacific Network of People Living with HIV/AIDS (APN+); the Coalition of Asia Pacific Regional Networks on HIV/AIDS, also known as the Seven Sisters, and the International Community of Women with HIV/AIDS (ICW). The partnership at country and regional levels also included researchers, civil society, people living with HIV and national AIDS commissions.

The agreement, which cements this commitment further, was signed in the presence of UNAIDS Director of the Asia Pacific Regional Support Team, Prasada Rao; Executive Director of the ASEAN Foundation, Filemon Uriarthe Jr; UNIFEM Regional Director East and South East Asia, Dr Jean D’Cunha; and APN+ Regional Coordinator and Director, Shiba Phurailatmam.

Speaking on the occasion, Mr Rao said, “The project is not only to understand what needs to be done but to pave the way to programmes that work on the ground.” He added that a range of strategies was needed, including scaling up efforts with key populations at risk in urban areas and through reproductive health programmes for rural women.

Dr D’Cunha stressed the importance of working on gender power dynamics, especially for positive women whose voices must be heard. “All the issues are interconnected and cannot be tackled by any one agency,” he said.

Mr Phurailatham stressed the need to approach women who are considered “low-risk” through their “high-risk” partners. He also stated that it was all the more important that laws criminalizing HIV were changed, as "laws that hamper HIV prevention, criminalize those men at risk can only have a negative impact on the lives of those women."

According to the agreement, funding from the ASEAN Foundation will be leveraged to aid the resources provided through UNAIDS, UNIFEM and UNDP.

HIV and Intimate Partner Relationships

In July this year representatives of AIDS commissions, UNICEF, WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria and 90 delegates from 15 Asian countries unanimously agreed that intimate partner relationships had to be included in national HIV policies and programmes. A report titled HIV Transmission in Intimate Partner Relationship in Asia was an outcome of this unanimous decision.

The report recommends that HIV prevention interventions be scaled-up for men who have sex with men, injecting drug users and clients of female sex workers. It also suggests that structural interventions should be initiated to identify and address the needs of vulnerable women and their male sexual partners.

When AIDS first emerged in the 1980s, it mainly affected men. Today, according to UNAIDS figures, women account for about half of the 33 million people living with HIV worldwide, and 60 per cent of those infected in sub-Saharan Africa. Most of these women acquired the virus through heterosexual intercourse, often through unprotected sex with their husbands or long-term primary partners.

“Women think marriage is a safe haven,” says Beauty Nyamwanza of Zimbabwe’s National AIDS Council. “They think that when you’re married, you don’t have to worry about HIV.”

But what the AIDS-prevention team in the country found out is that marriage can actually increase the risk of HIV among young women. According to research carried out in Kenya and Zambia in 2004 , marriage increases the frequency of sex and hinders a woman’s ability to negotiate condom use or abstain from sex. Married women are often afraid to ask their husbands to use a condom – or to use one themselves – since this implies that they suspect their husbands of infidelity.

Thanks to the efforts of Ms Nyamwanza and others, Zimbabwe is one of a handful of countries that has taken advantage of the female condom and made major inroads in promoting its use. The latest device, the FC2, is a strong, flexible, nitrile sheath, about 17 centimetres (6.7 inches) long, with a flexible ring at each end. The closed end is inserted into the woman’s body, and the open end remains outside during intercourse. Like the male condom, it offers dual protection against unintended pregnancy and sexually transmitted infections, including HIV. But it has one critical advantage: it is the only available technology for HIV prevention that women can initiate and control.

Condom promoters in Zimbabwe suggest that married women can present the female condom as a means of child spacing. In this way, the issue of a woman appearing to accuse her husband of having other partners and putting her at risk need not arise.

Building support

Zimbabwe introduced the female condom in 1997, but acceptance was slow. Eventually, the Government requested support from the United Nations Population Fund (UNFPA) to scale up promotion of both male and female condoms through the public sector. Beyond training condom promoters, highly creative ways to educate the public about condom use were employed. Billboards, radio spots and TV commercials helped break down taboos against talking about condoms, and thus helped overcome the stigma sometimes associated with them. In the process of implementing the strategy, the team – which included the Ministry of Health and Child Welfare, the Zimbabwe National Family Planning Council, the National AIDS Council and Population Services International (PSI) – discovered that the female condom can be a tool for empowerment, enabling women and adolescent girls to take the initiative in protecting their own reproductive health and that of their partners.

From 2005, when the strategy was launched, to 2008, female condom distribution by the public sector in Zimbabwe increased five-fold, from about 400,000 to more than two million. Sales of female condoms through social marketing rose from some 900,000 to more than 3 million, and sales of male condoms also increased.

Involving men

One person who has seen the change coming is Langton Ziromba. He owns a small, outdoor barbershop in the Budirio section of Harare. In addition to haircuts, shaves and chats about football and women, Mr Ziromba provides another service to his male customers: information about female condoms, how they are used, and the advantages to both partners. He is one of about 70 barbers and 2,000 hairdressers in Zimbabwe who have been trained to promote the female condom. He sells Zimbabwe’s most popular brand, called Care, and makes a small commission on the highly subsidised price.

“Our research shows that for this product to be accepted and used by women, we also need to involve men,” says Margaret Butau of the National Family Planning Council. “We customise the benefits of the female condom according to the target group we are addressing.” Specific points highlighted for men include the fact that the female condom is not constricting like the male condom, it is even less prone to breakage, its use does not require an erection and it can enhance pleasure for both partners. Moreover, it is not necessary to withdraw immediately after ejaculation. And, finally, it could be seen as the woman’s responsibility. “When we point all this out, we find that men become curious about having their partners try the product.”

Providing a model for other countries

The Zimbabwe campaign created by PSI that uses hairdressers to market condoms has served as a model for a similar programme in Malawi. Some 2,400 Malawian hairdressers now sell, and serve as advocates for, the female condom in the country. Their numbers are growing as word spreads. Sandra Mapemba, a national programme officer in the UNFPA office in Malawi, says the impact has been dramatic. “The female condom is actually empowering women to become more assertive and to stand up for their own health issues,” she says. “That’s the most exciting thing for me. Women who are in discordant relationships or women who are HIV-positive come and tell me that now they can actually insist on condom use. Before, their partners would refuse.”

The response has been so positive that UNFPA Malawi is now providing training in condom programming to some 35 international and local NGOs working on HIV-prevention in the country. Over the course of three years, female condom distribution through the public sector alone in Malawi increased from 124,000 in 2004-2005 to nearly a million in 2008.

Programming challenges persist

The success of UNFPA and its partners in promoting the female condom in Zimbabwe, Malawi and also in Zambia has prompted other countries to seek similar assistance. Though global distribution of female condoms nearly tripled from 2004 to 2008 – to a total of 33 million in 90 countries – they still represent only 0.2 per cent of condom use worldwide. Key barriers are cost and availability. Not only are female condoms more expensive than male condoms – they cost as much as $1 per unit in some countries – they are still far less widely available. Through an initiative called comprehensive condom programming, UNFPA is helping countries address these and other issues. The programme is also a platform from which other female-initiated prevention technologies still in development, including cervical caps and microbicides, will be launched.

“Giving women the power to protect themselves could turn the tide of the AIDS epidemic,” says Bidia Deperthes, who leads the comprehensive condom programming initiative for UNFPA. “But we still have a long way to go.” The largest obstacle, in her view, is funding for programming. While the majority of donors willingly contribute essential commodities, including male and female condoms, little money is allocated to laying the groundwork needed to create awareness and demand, and to train women to use condoms correctly and consistently. “It’s all part of one comprehensive package.”

This article was adapted from an upcoming UNFPA publication “Prevention Gains Momentum: Successes in female condom programming”.