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Prev Spotlight Condoms Final

Prev Spotlight Condoms Final

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Published by murphman

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Published by: murphman on Sep 28, 2012
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AIDSTAR-Oe SpOTlIghT On pREVEnTIOn
Reiviorati Codoms as a hIV prevetio Too
Krisa Jafa ad Steve Cama
The wrd is enticingy cse t reaizing thevisin f an AIDS-free generatin. Mre HIV-infected individuas are accessing treatmentearier in the curse f their disease, andeiminatin f vertica (mther-t-chid)transmissin—whie sti a chaenge—iscser t becming a reaity (Ciarane eta. 2012). Hwever, this visin cannt beachieved thrugh treatment ane. HIV wi ny sw dwn when new infectins,currenty at tw fr every ne persn put ntreatment, diminish dramaticay (Jint UnitedNatins Prgramme n HIV/AIDS 2010). Thismeans imprved access t, and utiizatin f,cmbinatin preventin—a mix f evidence-based HIV preventin interventins incudingcndms.
In this editorial, we summarize the evidence oncondoms or HIV prevention, discuss barriers andopportunities regarding supply, and propose ways toreinvigorate the use o condoms as an HIV prevention tool. This reinvigoration is needed now more than ever,given the vital role o condoms in both primary HIVprevention and in interventions to promote positivehealth, prevention, and dignity or people living withHIV.
Cndms Wrk, and Many Pepe Use Them
Condoms are an eective barrier method or preventing HIV, other sexually transmitted inections(STIs), and unintended pregnancy, and are used inhundreds o millions o sex acts each year (Davisand Weller 1999; Pinkerton and Abramson 1997; Weller and Davis-Beaty 2002). They play a key rolein sustaining the benets o other high-impact HIVprevention interventions such as male circumcisionand prevention o mother-to-child transmission. Thus,condoms are a vital component o a comprehensiveHIV prevention strategy.Condom promotion is generally considered a cost-eective HIV prevention intervention as measuredby the cost per disability-adjusted lie year (DALY)averted. The DALY is a composite metric thatcombines years lived with disability and years lost topremature death, and one DALY averted representsone year o healthy lie. While cost eectiveness ratiosare context-specic and there isn’t universal agreementon thresholds o cost eectiveness, a cost per DALYaverted ratio o under U.S.$50 is generally consideredcost-eective. The cost per DALY averted or malecondoms ranges rom U.S.$19 to $205, and thisrange indicates condom programs vary in design andimplementation (Jamison et al. 2006).Condom promotion can be controversial. Earlier in the course o the epidemic, there were concerns thatcondoms were being promoted in ways that ignoredstructural barriers and religious sensitivities, ailed to include communities, and potentially increasedpromiscuity (Peier 2004). Were these concernsoverstated? Perhaps. We now know that condoms
The views in this editria d nt necessariy refect thse f USAID r the U.S. Gvernment.
1 September 2012
 
2SPoTlIGHT oN PREVENTIoN
REINVIGoRATING CoNDoMS AS AN HIV PREVENTIoN Tool
have been essential to achieving signicant preventiongains in both generalized and concentrated HIVepidemics. For example, a recent modeling paper suggests that HIV incidence in South Arica among15 to 49 year olds declined by as much as 23 to 37percent rom 2000 to 2008—and that much o thisdecline can be attributed to increased condom use(Johnson et al. 2012). Similarly, in Zimbabwe, reductiono multiple and concurrent partnerships, high condomuse in non-regular partnerships, and improvedconsistency o condom use among women with their casual partners are thought to have contributed to a all in HIV prevalence rom 29.3 percent in1997 to 15.6 percent in 2007 (Gregson et al. 2010).Thailand’s program requiring 100 percent condomuse during commercial sex had similar results rom1991 to 1995 among young Thai men—condom useat last commercial sex increased rom 61 percent to92.5 percent, and HIV prevalence ell rom between10.4 and 12.5 percent to 6.7 percent (Nelson et al.1996). Similar successes are noted in other countries(Population Services International 2006; PopulationServices International 2009; Riedner et al. 2006; WorldHealth Organization [WHO] 2000).
But Nt Everyne Wants t Use—or Is Abet Use—Cndms
Despite proven eectiveness, there are still severalchallenges to condom use. Moving orward, programsmust address these barriers and incorporate (and test)potential solutions as part o any prevention strategy.
Risky Behavior 
Even the most ardent condom promoter will admit that it is dicult to promote condoms among couplesin established sexual relationships, one or both o whom may also have other sex partners. This is trueregardless o whether societal and cultural normscondone multiple and concurrent sexual partnerships(Halperin et al. 2011; Shelton 2006). Moreover, condomuse is sel-reported and survey respondents may  thereore adjust their answers according to what seemsmore socially desirable (Aho et al. 2010). Condompromotion without eorts to reduce the number o partners is only hal a solution.Two behavioral models o risk-taking provide insightsinto why people use condoms less oten, or stop usingcondoms altogether, even when they are aware thatcontinued use protects against HIV and other STIs.The risk compensation model suggests that when aneective prevention or treatment intervention (or oneperceived to be eective) is available, an individual’sperception o transmission risk may be reduced,which in turn can lead to increased risk-taking (Eiseleet al. 2009; Kelly et al. 1998; Tun et al. 2004). For example, men who become circumcised—and whoare thus partially protected rom HIV acquisition—may incorrectly perceive themselves to be at no risk or HIV,and thus may choose to discontinue condom use or tohave more sex partners. The behavioral disinhibitionmodel suggests that when an eective interventionsuch as antiretroviral treatment is available, an individualmay be less likely to exercise sel-restraint and morelikely to ocus on the pleasure o unprotected sex—andnot use a condom (Blower, Gershengorn, and Grant2000; Law et al. 2001; Wilson et al. 2008). Substanceuse is thought to urther increase such risk-takingbecause o its own disinhibiting eect.Both models o risk-taking help to explain the rationaleor stopping or reducing condom use among men whoare medically circumcised (Agot et al. 2007; Bailey etal. 2007; Gray et al. 2007), alcohol or substance userswith their partners (Fritz 2011), men who have sex withmen (MSM) (Grulich 2000; Hogg et al. 2001; Sampaioet al. 2002), and discordant couples (Allen et al. 2003;Coldiron et al. 2008; Eaton and van Der Straten2009). There is mixed evidence o consistent condomuse in some o these populations. Furthermore, theconcept o partial protection that is conerred by HIV prevention interventions such as medical malecircumcision, and the attendant need to continue usingcondoms consistently, is dicult to convey.
 
3
spotlight on prevention
reinvigorating Condoms as an hiv prevention tool
 
Understanding the underlying reasons or risk-takingbetter, and designing interventions based on thatunderstanding, becomes even more important with the U.S. Food and Drug Administration’s recentapproval o pre-exposure prophylaxis (U.S. Food andDrug Administration 2012). Messages may need toaddress several types o barriers—such as a risk-basedcalculation that condom use is not as necessary, or arousal-based barriers to condom use.
Structural Barriers
It is essential to consider, and address where possible,structural actors that may contribute to increased risk- taking. These barriers—including stigma, criminalization,and other legislative and social barriers—can impedecondom use in important ways. For example, even though we know that unprotected receptive anal sex is the most ecient route or transmitting HIV, condompromotion among MSM and transgendered peopleis patchy or absent in a number o countries (Ayalan.d.; Baggaley, White, and Boily 2010). A recent reportshows that limited or absent condom promotionresults rom criminalization o same-sex behaviors,homophobia, and discrimination against this vulnerablepopulation (Beyrer 2010; Global Commission onHIV and The Law 2012). When condoms, lubricants,and educational materials promoting condom useare used as evidence o crime, it becomes dicult toreach MSM—and other at-risk populations such assex workers—with these much-needed interventions.Sadly, such criminalization continues despite growingevidence that robust coverage o HIV interventions or MSM has positive epidemiologic eects and is cost-eective (Beyrer et al. 2011).
Dual Protection and Dual Use
Another prevention option that needs to be better understood is the use o condoms or dual protection(against STIs and pregnancy), as well as dual useo condoms plus one other modern contraceptivemethod to prevent unintended pregnancy and HIV transmission or re-inection (Pazol, Kramer, andHogue 2010; Prata, Sreenivas, and Bellows 2008).There is no globally accepted indicator or measuringuse o dual protection, and Demographic and HealthSurveys only report on the primary amily planningmethod used. These are missed opportunities tounderstand the impact o amily planning and HIVintegration programs—with potential negative impactson reduction o both heterosexual and vertical transmission (Wilcher and Cates n.d.).These and other challenges demand resh thinkingabout how to address impediments to equitable access,as well as rigorous evaluation o which elements o condom programming work—and, equally importantly,don’t work—in both concentrated and generalizedepidemics (Hearst and Chen 2004).
The Suppy Side: Wh Prcures andDistributes Cndms?
Next, we discuss who buys and distributes condomsor HIV prevention, quality considerations, and key challenges in condom commodity procurementplanning and orecasting.
Donor Contributions
Condoms are listed on the WHO’s Model List o Essential Medicines (2011). Male condoms are veraordable (U.S.$0.02–0.04per unit) and are widely distributed. In 2010, procurement o male condomsby bilateral and multilateral donors or public sector distribution and social marketing exceeded 2 billionor the rst time and refected a 22 percent increaseover 2009 (Reproductive Health Supplies Coalitionn.d.). The ve leading agencies that purchased maleand emale condoms in 2010 were the U.S. Agency or International Development (USAID; 37 percent), the UN Population Fund (UNFPA; 22 percent), theGlobal Fund to Fight AIDS, Tuberculosis and Malaria(9 percent), Kreditanstalt Für Wiederaubau (KW; 2percent), and the UK Department or International

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