Public Sector Condoms

5 February 2002

High-quality, SABS-approved public sector condoms are available, at no cost to the user, from almost all public health centres such as clinics and hospitals, and at informal outlets in the community

(Objective: Improve the image of public sector male condoms by providing factual information dispelling popular misconceptions, and re-assure the public of their availability from public health facilities and other outlets.)

South Africa has had a history of poor quality public sector condoms. This was largely due to the fact that quality was not regulated and manufacturers were able to deliver poor-quality condoms into the local market without detection.

This situation has improved dramatically in the last two years. All production lots of public sector condoms, regardless of where they are made, are tested to World Health Organisation (WHO) and National Department of Health (NDOH) standards and specifications.

Unfortunately, quality problems from the past are difficult to dispel. The current reality is that public sector condoms are tested to far higher quality standards than the commercial sector. Fancy packaging has no bearing on the quality of the condom itself.

Over the past 18 months, the NDOH has resolved problems of shortages and stock outs at the 190 primary delivery sites that it is responsible for in the provinces. However, the NDOH is aware that a great deal of work still needs to be done before condoms are available on a sustained basis to everyone who needs them at the community level. To this end, the NDOH is increasing its support to the provinces to initiate innovative community-based distribution programmes, and develop more effective public/private partnerships.

The facts are that:

CONDOM QUALITY

• all public sector condoms are designed and manufactured according to technical specifications set by the WHO
• every public sector condom has a lot number and expiry date printed on it
• whether condoms are made locally or imported from overseas, they are tested to the same quality standards

For information about condom quality control or to observe actual testing & certification by the SABS, contact du Toit Volschenk (tel 012-428 6493), or the NDOH's John Wilson (tel 012-321 3454)

DISTRIBUTION

• the DoH distributes condoms to 190 primary sites which in turn deliver to thousands of secondary outlets, such as shebeens and truck stops, and to large employers such mines and construction companies.
• during 2001 the DoH resolved the problems of stocks and distribution to the 190 primary delivery sites
• now there are enough condoms so that government doesn't have to ration anymore
• Although South Africa is the only sub-Saharan country to significantly reduce the difference between the number of condoms made available and the estimated number of sexual acts, community-level and individual-level supply still needs to be improved so as to close this "condom gap"

The term "condom gap" refers to the unmet need for condoms in preventing STIs, including HIV, and unwanted pregnancy. It is a way of identifying and quantifying the total number of condoms required for a national prevention programme, relative to the current absorptive capacity of the distribution system. For example, for the South African programme the NDOH will procure 358 million condoms for fiscal year 2002/3, based on the anticipated capacity of the distribution system to make those condoms available to communities and individuals. Obviously, if the distribution system becomes more efficient in reaching communities, more condoms will be distributed.

The issue is, what is the total number of condoms South Africa needs to turn the HIV epidemic around? Current data from researchers who track HIV infection rates and condom availability/use indicate that a public sector programme such as in SA requires between 700 and 800 condoms to avert a single HIV infection. At the current 1,700 new HIV infections per day, or 620, 500 new infections per year, this implies a total requirement of 465 million condoms. Thus we need to find ways of increasing community-level distribution and use of condoms to this level to maximise their effectiveness in reducing HIV infection rates.

[See also Closing the condom gap at www.jhuccp.org/pr/h9edsum.stm]
For information about the Dept of Health's condom sourcing, promotion, logistics & distribution activities, contact the DoH's John Wilson (012-321 3454)

FEMALE CONDOMS

• were first piloted in SA in 1998 at 29 public sector sites
• are now available at an expanded 114 public sector sites around the country, at no cost to the user. By the end of 2002 this number of public sector sites will grow to 200
• are approximately 22 times more expensive than male condoms
• give women more choice and control over sex
• ensure greater privacy because they can be inserted up to eight hours before the sexual act takes place
• are made from polyurethane, although some countries are exploring the possibility of using latex, a more affordable material than polyurethane
• are also available through social marketing. Social marketing refers to ways of increasing condom availability and use through aggressive marketing and advertising among populations that can afford a heavily-subsidised condom, but who could not afford a private sector condom. Currently, socially-marketed male condoms account for about 5% of the total number of public sector condoms distributed. Heavily subsidised female condoms are available in many pharmacies through social marketing.

There is only one internationally-approved female condom, manufactured by the Female Health Co, based in the UK.

CORRECT AND CONSISTENT USE OF CONDOMS

Using a condom consistently and correctly protects you and the one you love from Sexually Transmitted Infections and HIV/AIDS.

(Objective: Help counter resistance - especially amongst males - to condom usage, and promote the correct use of condoms in order to ensure their efficacy in preventing infection of STIs and HIV/AIDS.)

There is some evidence of resistance to using a condom, especially amongst males. . Additionally, condoms are sometimes used incorrectly. Countering such resistance, and ensuring correct condom use remains a challenge.

• Other than abstaining from sex, there is no better method than using a condom to prevent contracting a sexually transmitted infection. Condoms give the best protection when they are used correctly every time partners have sex
• condoms are especially valuable - they help prevent infection with STIs and they act as a contraceptive
• during STI Week public-sector health workers and counsellors are again emphasising that responsibility for using condoms should be shared by both partners. A caring approach to issues of sexuality and sex education should aim to strengthen the ability of women to negotiate condom usage with their male partners.
• Condoms are nearly 100% foolproof. Failure is more often than not due to incorrect use ie. user-failure and not condom-failure.
  Liberty Eaton & Alan J Flisher of UCT's Dept of Psychiatry & Mental Health (tel 021-404 2137] - amongst others, have researched the resistance to condom use amongst youth

CORRECT USE

• Sexually active people are encouraged to speak to a health worker if they or their partners experience problems using condoms
• Seeking advice about condom use, safe sex, STIs and HIV/AIDS is a sign of caring for oneself and one's sexual partners, and confidential advice on all these topics is available from the government Aids Helpline on 800-012-322.
• During STI Week (11-15 February), public sector health workers and counsellors will demonstrate correct condom use
• Leaflets demonstrating correct condom use are available from most public health centres
• Sexual partners are encouraged to explore new, stimulating, and safe ways to use condoms
• See www.plannedparenthood.org/condoms/history.html for more on the history of condoms & condom use
  

STIs AND HIV/AIDS INFECTION

Sexually Transmitted Infections, especially if untreated, put you and your partner at greater risk of contracting HIV/AIDS.

(Objective: Increase awareness of the link between STIs and HIV/AIDS, and to encourage persons displaying STI symptoms to reduce their vulnerability to HIV infection by seeking treatment.)

Research in recent years suggests that treating STIs early and effectively significantly reduces the risk if HIV infection.

In Mwanza, Tanzania, the rate of HIV infection was reduced by 42% over two years through the early and effective treatment of STIs using syndromic management.

Two South African projects, Mothusimpilo (Carletonville), and Lesedi (based at the Harmony gold mine in Virginia, Free State) have worked to pioneer syndromic management of STIs. Tony de Coito (0834524087 / tdecoito@rel.co.za) serves on the management structures of both projects, and is a wealth of information as to the efficacy of this approach.

DANGERS OF UNTREATED STIs

• STIs cause sores, weakening the skin of the penis or vagina and making it easier for HIV to enter the body. Persons with an STI are up to 9 times more likely to get HIV if they don't seek treatment immediately
• STIs, if untreated, can result in serious illness and infertility.
• STIs can also be passed on to an unborn or newborn baby by an infected mother.
• most STIs are easily treated
• while STIs are easily and effectively treated, the full course of treatment must be followed through to the end, otherwise the disease will not be cured.

SYMPTOMS OF STIs

Know what the symptoms of Sexually Transmitted Infections are, and notify your partner of any such symptoms.

(Objective: Familiarise sexually active persons with the symptoms of STIs, and to encourage partner notification.)

Sexually transmitted infections (STIs) are diseases caused by germs - bacteria and viruses - that are passed from one person to another during sexual intercourse.

STIs are passed from an infected person to others through unprotected vaginal, oral and anal sex

Once visible, the symptoms of some STIs can be easily identified.

However, with some STIs there are no visible or easily-identified signs, and STIs are usually much harder to diagnose in women.

STIs are usually identified by one or more of the following symptoms:

• pus or smelly fluids coming out of the penis or vagina
• blisters, sores, or warts on the penis or vagina
• pain or burning when urinating
• pain during sex
• pain in the lower abdomen
• unusual swelling near the penis or vagina
• itching on or near your genitals.

Judith Wright, a nurse employed by the Gauteng department of health, is regarded by her peers as someone who works especially hard to find ways to encourage sexually active persons to notify their partners about STI symptoms, and to get partners to also seek treatment. She can be contacted on 011-489 9494.

STI TREATMENT

Good-quality treatment for Sexually Transmitted Infections is available, at no cost, at most public health centres. STIs can be cured - seek treatment immediately!

(Objective: Check it, Treat it, Beat it, i.e. to encourage early seeking of treatment for STIs, available at no cost from public health centres.)

• Many people are not aware that confidential treatment, information & counselling are available from almost all public, and several private, and joint public-private sector health centres.
• With syndromic management, health workers do not try to diagnose specific STIs (which usually requires relatively sophisticated laboratory procedures). Instead, they use an algorithm of decision points and specific regimens to treat syndromes such as vaginal discharge, urethral discharge (in men), genital ulcers and pelvic pain.
• Syndromic management of STIs was piloted in 1996. Those trained in syndromic management have gone on to train others around the country. An audit carried out in 1999 revealed that 80% of public health facilities have a health care professional using the syndromic management approach.
• Infection rates for some STIs have already dropped: for syphilis it was 10% of all persons attending clinics and being tested for STIs - it is now 4%.
• Considerable focus in STI treatment and counselling programmes is placed on truck drivers and sex workers. Many sex workers operate on routes and at stops frequented by truckers. Many stakeholders - the Dept of Transport, the road transport bargaining council, the Dept of Health - support initiatives such as the roadside clinics at Harrismith, Beaufort West, and one to be formally launched at Messina during STI Week.
• Truckers working routes in Mozambique can seek treatment at one of three facilities in that country run by the Germany Agency for Technical Co-operation (GTZ)
• Many people prefer to use traditional healers for their health needs. The Dept of Health communicates with some 350 traditional healers to promote STI awareness and counselling.

TREATMENT

• Persons who think they may have an STI should immediately go to a doctor, clinic or hospital for treatment. The partner of a person presenting STI symptoms or being treated for an STI should also seek treatment.
• Health workers see STI patients privately, and everything discussed is treated confidentially
• STIs can be cured with pills or cream. Sometimes an injection is given.
• Treatment at public health facilities is of good-quality and medication is provided at no cost.
• Persons being treated for STIs are encouraged to complete their course of treatment, otherwise they may not be cured.

[see Reddy P, Meyer-Weitz A, Van Den Borne B, Kok G. Determinants of Condom-use behaviour among STD clinic attenders in South Africa. International Journal of STD & AIDS. July 2000 Vol 11 (8)]