The Ugandan Ministry of Health (MOH) guidelines on HIV prevention emphasizes the use of condom as a prevention strategy. Over time condom use as a prevention strategy has performed well and greatly contributed to reduction in cases of new infections among the general population and key populations. This was proven during the community score card conducted by Action Group for Health, Human Rights and HIV/AIDS (AGHA-Uganda) in public health facilities in Kampala, Wakiso and Mukono districts. The demand for male condoms remained high an indication that it is a popular prevention method among both male and females. Thus in terms of demand the male condoms were performing well given the level of availability and access at the given facilities.
The case is however different for female condoms. Despite its availability the demand and utilization of female condoms as a prevention strategy among females in the general population and female sex workers in particular was a concern. The demand currently stands at about 1% to 2 % compared to the male condoms at over 98%. The implication is that while the men take full charge of their sexual encounters, female folks are limited and thus remain susceptible to infections.
A number of challenges were raised surrounding the access and usage of female condoms. Most female clients interviewed revealed the down side of the female condom as being difficulty in managing it, citing its design makes it rather bulky and cannot be concealed as the male condom. To others the condom makes a squeaky funny sound that compromises privacy of individuals during intercourse, has a slippery nature that makes it easily slip off, plus it is quite unpopular and pricy in private facilities hence limiting access by would be users.
The MOH procured and supplied about 1.5 million female condoms annually using Global Fund grants at the expense of other essential supplies like STI drugs with the hope that it would contribute significantly to HIV prevention among sexually active women. Unfortunately as mentioned above, uptake of female condom remains low among women in the general as well as most at risk population. This directly compromises efforts towards HIV prevention among key populations.
If not addressed, the issue of low utilization of female condom is likely to contribute to new HIV infections among young women (18-44) in Uganda, more cases of other STIs among female sex workers and unwanted pregnancies. Thus given these challenge priority should be given to rectifying issues around female condoms that would serve as a double edge sword in addressing both HIV and STI issues as well as unwanted pregnancies among young women.
The burden is even heavier for Sex workers who become more prone to STI given their kind of sexual debut. Having several sexual encounters with different partners in itself is enough to expose the female sex workers to infections of different STIs. Engaging in these encounters without condoms aggravates the situation further leaving the women more susceptible to infections.
It is a manifestation of women not being in charge of their sexual life and therefore raises issues of power relations that no doubt leads to sexual and gender based violence. The whole idea of women not being in control undermines efforts to reduce new infection rates in both the general and key populations. It thus calls for adequate sensitization of women to empower them take charge of their own health.
Strategies to address the challenges
Ministry of Health should conduct massive sensitization and awareness on the existence and usage of female condoms as a preventive measure besides other bio medical interventions. Adequate sensitization on the significance of female condom would to a greater extent create and increase demand among female users.
Health workers and other players should scale up accessibility and availability at public health facilities and other public places. These points should be equipped with regularly filled dispensers that are strategically placed not to compromise privacy of the users.
The government through Ministry of Health should liaise with other stakeholders to identify an alternative female condom available on the market. This will address issues surrounding its design and marketability. An alternative design for female condom like a panty condom which has been tried in other parts of the world could be explored to address the challenges regarding size and design.
Introduce a mandatory condom policy at all brothels where the female sex workers operate to ensure they access and utilize condoms dispensed. Every potential sex client should be given a condition to use condom or be denied service. That way the female sex workers will feel empowered and in control.