Objectives of the Session

1. Implementing Male and Female Condom Programmes at the Community Level:Experiences from Nigeria and ZimbabweBy Chris Oyeyipo (UNFPA, Nigeria) andDaisy Nyamukapa (UNFPA, Zimbabwe)

2. Objectives of the Session • Share with participants basic information on male and female condoms • Discuss information on the relationship of condom programming and dual protection against HIV/AIDS and unintended pregnancies • Outline basic steps required to promote condoms at community level • Share examples of successful community involvement in CCP from Zimbabwe and Nigeria

3. Basics on Male and Female Condoms Male condom • Made of latex, natural membrane, polyurethane • Offers dual protection against HIV and unintended pregnancies • Requires an erect penis for usage Female condom • Made of polyurethane or synthetic latex (nitrile) sheath • May be inserted into the vagina up to 8 hours before intercourse • Provides dual protection against STI/HIV and unintended pregnancies • May provide better protection against STIs due to skin infections • Durable and offer women greater control

4. Epidemiological Context Zimbabwe • Zimbabwe is in an advanced state of a generalized HIV epidemic. • Sexual Transmission accounts for 80 to 90% of all HIV cases • Of the 1.6 million living with HIV & AIDS in Zimbabwe, 56% are women • Preliminary results of the 2005-2006 DHS indicates a disparity in adult prevalence rate between males and females (21.1% females compared to 14.5% in males) Nigeria • Sero-prevalence currently at 4.4 % • Sexual Transmission accounts for about 90% of all HIV cases • An estimated 2.9 million people live with HIV & AIDS in Nigeria - 3rd highest figure in the world • Prevalence in the age group 15-24 is currently at 5.2% • Adolescent girls twice more vulnerable than boys

5. HIV Prevalence Among Couples in Zimbabwe:(Zimbabwe DHS 2005-06 Preliminary Report)

6. Social Context: Zim. & Nigeria • High prevalence of rural/urban separation of spouses • Sexual roles for men and women are defined differently and are unequal • Unequal power relations in sexual relationships leads to difficulties in negotiating for safer sex • Women’s weaker economical position increases dependence on men • Limited choices of HIV prevention methods esp. those that women control • Women often subjects of sexual violence i.e. rape • Suggestions of condom use may result in violence • Relatively wide promotion of the male condom, but this is controlled largely by men, thus insufficient in addressing women’s HIV prevention needs

7. Condoms and Dual Protection • Condoms are the only devices that offer dual protection • Only devices that protect against sexually transmittedinfections including HIV • Consistent use reduces HIV risk byabout 90% • With perfect use, pregnancy rate for male and female condoms is between 3-5%

8. Steps to Effective Condom Programming • Understand condom clients and environment e g acceptability studies, Situation analysis etc • Assess condom programmes and create action plans e g participatory development of national condom strategy and operational plans with NGOs/CBOs/FBOs • Procure high quality condoms and manage pipeline • Expand distribution points (Hair saloons, CBDs, Peer counselors, male motivators) • Promote condoms (BCC and IPC and negotiation skills for safer sex) • Monitor programmes with involvement of stakeholders including NGOs/CBOs/FBOs

9. Strategies in NGO/FBO/CBO Involvement • Coordination-Formation of condom stakeholder group • Capacity building to include personnel of NGOs • Participatory development and distribution of promotional materials • Commitment/partnership through linking NGOs/CBOs/FBOs for condom supply to the public sector and social marketing supply pipeline.

10. Operationalizing the Male/Female Condom Strategy, Within the Context of the National AIDS Strategy and RH Programme

11. Promoting Condoms at Community Level • Expand service delivery points within the community, e.g. village condom holders, hair salon “Care’ (FC) promoters • Counseling and educational materials should be gender sensitive and address underlying gender issues • Counselors should have gender skills • Integrate condom programme into RH and HIV/STI prevention programmes e.g. VCT, PMTCT, ANC, and MCH/FP • Conduct advocacy with men’s groups, community and religious leaders • Work with men (male motivators) and community leaders as advocates and role models for FC use • Create community dialogue between men and women • De-stigmatise condom use and promote consistent use • Monitor programmes

12. Phases of the Zimbabwe FC Strategy

13. Zimbabwe Established TSG on condom programming Undertook FC situation analysis Developed FC strategy Developed a draft FC manual Trained 40 master trainers (TOT) Trained 145 Community based Distributors Trained 92 District AIDS Coordinators and programme officers Trained 90 Nurse trainers Trained 61 Group leaders Nigeria Established FC stakeholders group Established National condom TSG Undertook FC situation analysis Drafted integrated condom strategy document Developed a draft FC manual Trained 80 master trainers (TOT) Trained 200 Community based Distributors Trained 50 male motivators Trained over 700 FC service providers and counsellors from public sector and NGOs Achievements to Date

14. Zimbabwe Female Condoms Sales/ Distribution By Year Social Marketing and Public Sector

15. FC Distribution-Nigeria (2003-06)

16. Behavioural change and declining HIV incidence/prevalence in Zimbabwe HIV prevalence decline X Mortality HIV incidence decline Emigration ofPLWHA ? ? Increased mortality among persons with high infection risk Behavioural change Emigration of persons with risky life-style Other factors:STI treatment: possibly YESTrends in MC, blood safety: NO ? ? ? • Abstinence • No clear trend- Age of debut among highest • in Africa since 1980s • Faithfuln./# of partners • Decrease in mean number of partners; but no trend data on concurrent relations- Polygamy stable up to 1999 • Condom use • Steady increase indistribution and sales data • Increase in use withnon-cohabiting partners Other-No trend data on intravaginal practices,widow inheritance,girl-child pledging, rape ? Programmes on delayed debut: FBOs, NGOs, education system Little programme focus on faithfulness, prevention in marriage, polygamy Public sector and social marketingcondom programmes Little programme focus on addressing theserisk factors Basic knowledge and personal experience of morbidity and mortality

17. Monitoring and Evaluation of Condom Programmes at Community Level • No of young persons accessing condoms • Percentage of clients reporting correct and consistent use of MC/FCs • MC/FC stock out rate in distribution outlets • Quantity of MC/FC distributed in the last 12 months • MC/FC at last sex with cohabiting/non-cohabiting partner(s)

18. Challenges and Barriers • Challenges • Human resource constraints • Limited availability of funds, especially hard currency • Donor dependence • Barriers • Myths and misconceptions • High cost of the female condoms (Nigeria) • Power imbalance between men and women compromising negotiation for safe sex • Limited availability in underserved communities (Nigeria)

19. Lessons Learnt • The unequal distribution of power between men and women, their ability to negotiate and respect each other’s freedoms influences utilisation of the female condom • Without involving men and empowering women with negotiating skills, the same issues influencing low-utilisation of the male condom, likely to affect the FC • Need for alliance/partnership building not only at national level (between donors, govt. and civil society), but also at operational level with male community leaders, male role models ensures sustainability • Role of Government in facilitating a conduce policy and regulatory environment critical • Promotion messages for the FC should be designed in a way that does not undermine the male condom to ensure complimentarity of the two methods

20. AsanteTatendaThank You