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”.

UNAIDS Executive Director Michel Sidibé joined the Chief Minister of Karnataka, B.S. Yediyurappa at the official launch of the Ashodaya Academy, Bangalore 12 October 2009.
Credit: UNAIDS

In Bangalore earlier today, UNAIDS Executive Director Michel Sidibé joined the Chief Minister of Karnataka, B.S. Yediyurappa at the official launch of the Ashodaya Academy – the first learning site on HIV in the Asia-Pacific region run entirely by sex workers. The Chief Minister welcomed the opening of the centre in Mysore, which begins its first HIV training course with over 200 sex workers from Ashodaya, as well as participants from as far away as Bangladesh, Cambodia, India, Myanmar and Nepal.

Michel Sidibé praised the commitment of the Chief Minister for taking time out from the ongoing relief and rehabilitation efforts of flood-hit Karnataka. "In the midst of the humanitarian crisis you are facing, your support for HIV is a special sign of your leadership and commitment to poor and vulnerable people without a voice," said Mr Sidibé.

“It’s a proud moment for us and we have come together to fight the spread of HIV,” said Prathima, a sex worker from in Mysore.

The Ashodaya centre will build the capacity of organizations to improve and develop community-led approaches for educating sex workers about HIV.
Credit: UNAIDS

Ashodaya Samithi, an association of sex workers in Mysore also expressed their appreciation that Chief Minister B.S. Yediyurappa had taken the time to attend the opening and offered his public support to them. The association of sex workers made a donation to the Government of Karnataka of 50,000 rupees, which their organization had collected in support of flood relief efforts.

The Chief Minister expressed how deeply he was touched by the charitable donation, saying that a donation of this size from them meant more to him than a donation 10,000 times larger from wealthy sources.

UNAIDS Country Coordinator Charles Gilks said that the donation symbolized even more than its monetary value, representing “an outstanding example of one community supporting their brothers and sisters in another community in time of emergency and need.”

Karnataka has a relatively advanced HIV epidemic. The state is the second highest prevalence state in southern India with the adult HIV prevalence in several districts exceeding 1% for the past 9 years. Sex work is a key factor in HIV transmission in Karnataka. Mapping exercises have estimated there are more than 64,000 female sex workers in urban areas, and 61,000 in rural areas.

Outreach to these sex work communities is a vital part of the AIDS response in this region. The Ashodaya Academy will build the capacity of organizations to improve and develop community-led approaches for educating sex workers about HIV and it is supported by the Bill and Melinda Gates Foundation, the University of Manitoba and the Asian Development Bank in partnership with UNAIDS.

Male circumcision among heterosexual men in high HIV prevalence and low male circumcision settings is beneficial and cost effective, says a new article in the open access journal PLoS Medicine.

The report is based upon the findings of a series of meetings, convened by UNAIDS, the World Health Organization (WHO), and the South African Centre for Epidemiological Modelling and Analysis (SACEMA). These meetings reviewed published and unpublished modelling work to estimate the long-term population impact and cost-effectiveness of male circumcision programmes through mathematical modelling approaches.

Six models were considered by the expert group, which was led by Dr. Catherine Hankins, Chief Scientific Advisor at UNAIDS. The models predicted that, using a 10 year time horizon, one new HIV infection would be averted for every five to 15 men newly circumcised. For the most successful interventions, where almost all men are circumcised, HIV incidence could be reduced by 30% to 50% over the same period, with prevalence trends also following this decrease.

The estimated costs per adult male circumcision are between $30 and $60, depending on the programme setting, with neonatal circumcision costing about one-third this amount. The models estimate costs per infection averted of between $150 and $900 in high HIV prevalence settings over a 10-year time horizon.

All the models indirectly confirmed that the most favourable cost-effectiveness ratios will be seen where HIV incidence is highest. By comparison, estimates of discounted lifetime treatment costs typically exceed $7,000 per HIV infection if only first-line treatment is provided, and twice as much if second-line treatment is available. Thus, circumcising sexually active males of any age is likely to be cost saving.

While several studies have confirmed that male circumcision performed by well-trained medical professionals reduces the risk of men acquiring HIV through female-to-male transmission by approximately 60%, a major concern raised in discussions around male circumcision, is that it does not directly protect women from HIV. However, women do benefit indirectly from reduced HIV prevalence in circumcised male sexual partners as male circumcision programmes scale up.

Male circumcision does not replace other prevention measures. Because it provides partial protection, it should be combined with strategies such as delaying the onset of sexual relations, abstaining from penetrative sex, reducing the number of sexual partners, using male and female condoms correctly and consistently, learning your HIV status, and getting treatment for sexually transmitted disease.

Male circumcision may have minimal impact on reducing HIV transmission among men who have sex with men.

L to R: Dr Jean D’Cunha, Regional Director, UNIFEM South Asia, Jeff O’Malley, Director, HIV/AIDS Group, UNDP and Dr Prasada Rao, Director, UNAIDS Regional Support Team Asia and the Pacific during the launch of the report HIV Transmission in Intimate Partner Relationships in Asia at ICAAP 09. Credit: UNAIDS/Donang Wahyu

It is estimated that more than 90% of the 1.7 million women living with HIV in Asia became infected from their husbands or partners while in long-term relationships. By 2008, women constituted 35% of all adult HIV infections in Asia, up from 17% in 1990.

A new report by UNAIDS, its Cosponsors and civil society partners, being released at the 9th International Congress on AIDS in Asia and the Pacific in Bali, HIV Transmission in Intimate Partner Relationships in Asia, examines the issue of married or in long-term relationships women who are at risk of HIV infection due to their partners’ high-risk behaviours.

The evidence from almost all the countries in Asia indicates that women are acquiring HIV not because of their own sexual behaviours but because of the unsafe behaviours that their partners engage in. The intimate partners of men who have sex with men, injecting drug users or clients of sex workers constitute the largest vulnerable population in Asia.

At least 75 million men regularly buy sex from sex workers in Asia, and a further 20 million men have sex with other men or are injecting drug users. Many of these men are in steady relationships: it is estimated that 50 million women in the region are of risk of acquiring HIV from their partners.

The report notes that men who buy sex constitute the largest infected population group – and most of them are either married or will get married. This puts a significant number of women, often perceived as ‘low-risk’ because they only have sex with their husbands, at risk of HIV infection.

The myriad issues that are at the root of the problem are discussed. The strong patriarchal culture in the countries of Asia, intimate partner violence, including sexual violence, the large-scale migration and mobility of populations in Asia and HIV-related stigma and discrimination all play a role in the vulnerability of women to HIV.

Dr Prasada Rao, Director, UNAIDS Regional Support Team Asia and the Pacific during the launch of the report HIV Transmission in Intimate Partner Relationships in Asia at ICAAP 09. Credit: UNAIDS/Donang Wahyu

“HIV prevention programmes targeting the female partners of men with high-risk behaviours have yet to be developed in Asia, but are clearly essential,” said Dr Prasada Rao, Director, UNAIDS Regional Support Team Asia and the Pacific, speaking at the launch of the report. “Investing in such programmes is key to reversing the AIDS epidemic in Asia once and for all.”

The report recommends four main strategies that should be implemented in addition to increased services for key populations:

1. HIV prevention interventions must be scaled-up for men who have sex with men, injecting drug users, and clients of female sex workers and should emphasize the importance of protecting their regular female partners.
2. Structural interventions should be initiated to address the needs of vulnerable women and their male sexual partners. This includes expanding reproductive health programmes to include services for male sexual health.
3. HIV prevention interventions among mobile populations and migrants must be scaled-up and include components to protect intimate partners.
4. Priority should be given to operations research to develop a better understanding of the dynamics of HIV transmission in intimate partner relationships.

It is hoped that the report will be a wake-up call that highlights the effects of the HIV epidemic on this hitherto most-neglected population.

Cover of Swaziland report.
Credit: UNAIDS

If national HIV prevention strategies are to succeed, countries must understand the character and drivers of their epidemic and focus on proven need through sustained and effective interventions. However, there is often a mismatch between HIV prevention efforts and the actual factors driving new infections. This can lead to significant resources being invested in programmes of limited effect which do not reach those most at risk. To address this situation in five African countries, National AIDS Authorities, UNAIDS and the World Bank have produced a series of detailed reports that aim to characterize the true nature of the respective epidemics and their drivers, the existing HIV prevention response and the allocation of funding for prevention.

Drawing on new and existing data, final synthesis reports from Kenya, Lesotho, Swaziland and Uganda look at the expected distribution of new infections over the next 12 months. (Mozambique, the fifth country, will release its study soon and Zambia is also preparing a report). On the basis of all the data, the reports assess the alignment between this evidence and the HIV policies and interventions in the countries. The four reports then offer recommendations to improve national HIV prevention strategies. Already, they have begun to feed into existing national planning and policy deliberations, in some countries going as far as informing development and review of prevention strategies and policy guidance.

“AIDS continues to undermine every effort and investment towards human development in this region. Countries, therefore, cannot afford to ignore the pressing need to review national HIV prevention strategies to ensure greater efficacy,” said Mark Stirling, Director of UNAIDS Regional Support Team for Eastern and Southern Africa. He added, “The leadership demonstrated by the countries that have undertaken this analytic work is a first and important step towards building effective prevention strategies.”

The studies give very specific illustrations of challenges emerging from the relative lack of evidence-based policies and programmes, while acknowledging that all of the countries have made considerable progress in addressing HIV and that several have seen their epidemics stabilize.

In Lesotho, for example, which has the third highest adult prevalence in the world, the study shows that there is an “exceptionally high” number of multiple and concurrent sexual partnerships before and during marriage. The bulk of new infections in 2008 were likely to occur in those reporting a single-partner (35-62%) and people in multiple partnerships. Yet, according to the report, national prevention strategies do not explicitly address concurrent partnerships and no activities are designed specifically for adults, married couples and people in long-term steady relationships.

The Kenya report describes a mixed epidemic that varies considerably across the country, requiring interventions planned and implemented at local level. However, strategies were found to be “general and overarching” and not specifically aimed at most-at-risk populations, which include those in certain mobile occupations such as the fishing community and truck drivers. Even where the evidence shows a clear need for it, Government funding aimed at other most-at-risk groups, such as sex workers, their clients, men who have sex with men and injecting drug users is “negligible or non-existent”.

It emerges, therefore, that across the countries significant resources are invested in a range of prevention interventions that are not rigorously evaluated for their “impact or quality” and, for some, spending on prevention is considered simply too low. (Spending in this area varied from 13% of the national AIDS budget in Lesotho where adult HIV prevalence is 23.2%, to 34% of the AIDS budget in Uganda with adult prevalence of 5.4%).

According to Debrework Zewdie, Director of the World Bank’s Global HIV/AIDS Unit, "The current global economic situation has made it more important than ever to get the most impact possible from our investments in HIV prevention. These syntheses use the growing amounts of data and information available to better understand each country's epidemic and response, and identify how prevention might be more effective. They are guiding the programmes we support."

The reports give concrete recommendations on how to move towards a more efficient use of resources through more evidence-informed prevention strategies. For example, Uganda recommended the establishment of clear policies, standards and guidelines to improve counseling and testing services, IEC and behaviour change interventions for married and long-term sexual partners, people living with HIV and at risk groups. Swaziland also recommended that married, cohabiting and steady couples be acknowledged as a priority population and, further, that stronger political leadership for HIV prevention be exercised in order to build widespread engagement to address the complex norms underlying the level of vulnerability to infection in the country.

The National AIDS Authorities and the UNAIDS and World Bank teams who have produced these wide-ranging and rigorously researched reports see them as an initial round of synthesis work which will form part of ongoing AIDS-related evaluations aimed at strengthening and sharpening national responses to the epidemic.

Note: The Analysis of Prevention Response and Modes of Transmission Study series is part of a programme of work led by National AIDS Authorities and UNAIDS Country Office teams with support from the UNAIDS Regional Support Team for Eastern and Southern Africa, UNAIDS Geneva and the World Bank's Global HIV/AIDS Programme.

This story was first published on UNFPA.org

Clients at Kevin's Reflextions have an opportunity to talk about HIV.
Credit: Carina Wint

Barber shops across Georgetown, Guyana, are buzzing with chatter about the latest trends, community happenings, neighbourhood gossip and now, ways to protect young people from AIDS. The United Nations Population Fund (UNFPA), in collaboration with UNAIDS Secretariat, has identified barber shops and beauty salons as information hubs, and is using them to spread the word about HIV prevention.

The project involves the training of shop staff to answer simple HIV-related questions, pass out informational material, dispense both male and female condoms to clients – and even provide on-site counselling and testing. As a result, young people in Guyana are given access to information and resources not readily available elsewhere in their communities. And this is important because their small country (population 751, 223) has one of the highest HIV prevalence levels in the region: about 1.6 per cent for pregnant women, according to UNAIDS. Among sex workers, prevalence rises up to 26.6 per cent.

Male and female condoms are available at selected hair salons.
Credit: Carina Wint

Juanita Huburn, a customer at DJ’s Magic Fingers, a hair salon that participates in the programme, described Guyanese society as “closed” when it comes to issues regarding sexuality. “You do not talk about sex, they just say you should not have sex, but this is not realistic,” she said.

Shops and salons were chosen based on their location in malls, parks, popular attractions, or low-income communities. Owners who opened their doors to the project got added marketing exposure for their small businesses and were provided with incentives, such as access to promotional materials. “Shops were informed how their companies would be promoted through the project, and the economic value of participating,” said UNFPA Guyana Liaison Officer, Patrice La Fleur “They would most importantly provide safe places to discuss sexuality and the prevention of HIV.”

Once the locations were identified, two employees from each shop were sent for training on basic HIV education and prevention means. They were also taught to properly monitor the project and introduced to safe practices within the context of their own work (for example, ensuring the sterility of hair cutting machines, razors, needles for stitching and weaving, manicure and pedicure implements, and tattooing and body piercing equipment).

In addition to training participants about sexual and reproductive health and gender issues, the project also focuses on building life skills such as communication, healthy relationships, and leadership. “Participants expressed personal gains in their quality of relationships with friends, family, and clients,” said UNFPA Programme Officer, Babsie Giddings who monitors the project.

DJ's Magic Fingers hair salon is another venue for building awareness of HIV prevention.
Credit: Carina Wint

Since the programme was put in place businesses report a steady boost in clientele and more shops have come on board. “Business has increased about 5 per cent since we joined this programme,” said Kevin John, owner of the Barber Shop Kevin’s Reflections. He believes it may be partly because people know his salon equipment is sanitized. Currently over 7000 male and 400 female condoms are distributed monthly by requests in the shops and salons.

Work on the project was initiated last year through efforts of the UN Country Theme Group and it has been fully funded by UNAIDS. Also collaborating on the project is a local NGO, Youth Challenge Guyana.

UNFPA provides continuous support with regular follow-ups and monitoring for participating barber shops and salons. The project aims to afford some 2000 young people access to information, skills, services and supplies they can use to protect their health.

Michel Sidibé, Executive Director of UNAIDS visited workers from two organizations to get first hand experience of how they carry out their outreach work among Pattaya’s sex work community.
Credit: UNAIDS/Vinai Dithajohn 

Picking her way through the crowds Surang Janyan waves a friendly hello to her friend Gop. This is one of the many people she will meet tonight in Pattaya’s Walking Street – a long street running along the cost of one of Thailands red light areas.

Surang Janyam is the Founder and Director of Swing, a small organization which provides support for sex workers in Thailand. She regularly visits Gop around midnight to check whether she or her staff need anything. Gop is the owner of one of Pattaya’s most popular bars, the Wild West Boys, where men go to watch a show and pay to spend time with the male sex workers, in the bar or for sexual services in private.

Gop has around 70 sex workers working for her and Surang knows many of them well. “Swing workers come to talk to us and give us condoms,” said Gop. “And they show the boys how to use them properly.” Swing members and volunteers distribute several thousand condoms each month and provide information about HIV and how to protect themselves against the virus.

“HIV among sex workers and access to services are among the biggest challenges to the AIDS response in Thailand,” said Michel Sidibé, Executive Director of UNAIDS. “It is extremely important that sex workers gain access to HIV prevention and treatment services without fear of discrimination.”

Swing works with a lot of bars and bar owners particularly. “Gaining the confidence of the bar owners is an important entry point for gaining access to the sex workers themselves,” said Patrick Brenny, UNAIDS Country Coordinator in Thailand. “Knowledge about HIV is worryingly low among sex workers in Thailand, at around 28% and it is important that they receive education about how to protect themselves and their clients.” Further down the Street Surang meets another of her friends Nueng who works for Sisters, the first counselling service in Thailand to cater exclusively for the transgender community. Pattaya is home to around 1000 transgenders in high season.

“We set up the centre in 2005 to get public support and greater acceptance of the transgender community in Pattaya,” said Nueng who is the Sisters Outreach Supervisor. “Before we started the transgender community had nowhere to go and no one to turn to for advice and support. There were services for male and female sex workers but nothing for transgender, we were on our own and people didn’t understand us.”

Pattaya, became the favourite ‘rest and recreation’ place of US troops during the Vietnam war and has since become a well trodden path on the sex tourism trail drawing in thousands of visitors a year.

Sisters, like Swing runs a drop-in centre in Pattaya where they provide medical services, counselling, skills development as well as club activities such as make-up, sports and cooking.

Nueng is transgender herself and so understands the stigma and discrimination faced by the transgender sex workers. “We have many problems because we are transgender,” she said. “If we try to access health services staff are often very unkind to us and treat us unfairly. So we try to offer our transgender sisters support and broaden awareness in the community so that people will accept us.”

Nueng wears a T-shirt the group printed for themselves so that they can be easily recognised when they carry out their outreach work. The T-shirts are bright pink and carry the words ‘Sisters, where our second home is.’

Michel Sidibé, Executive Director of UNAIDS visited workers from the two organizations this week to get first hand experience of how they carry out their outreach work among Pattaya’s sex work community. Working in partnership with sex workers to identify their needs and to advocate for policies and programmes that improve their health, safety and engagement in the AIDS response is a proven strategy and an essential feature of UNAIDS approach.

[Originally published in 2004 updated in 2009]

Condom use is a critical element in a comprehensive, effective and sustainable approach to HIV prevention and treatment.
Credit: UNAIDS

Condom use is a critical element in a comprehensive, effective and sustainable approach to HIV prevention and treatment. Prevention is the mainstay of the response to AIDS. Condoms are an integral and essential part of comprehensive prevention and care programmes, and their promotion must be accelerated. In 2007, an estimated 2.7 million people became newly infected with HIV. About 45% of them were young people from 15 to 24 years old, with young girls at greater risk of infection than boys.

The male latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections.

The search for new preventive technologies such as HIV vaccines and microbicides continues to make progress, but condoms will remain the key preventive tool for many, many years to come. Condoms are a key component of combination prevention strategies individuals can choose at different times in their lives to reduce their risks of sexual exposure to HIV. These include delay of sexual initiation, abstinence, being safer by being faithful to one’s partner when both partners are uninfected and consistently faithful, reducing the number of sexual partners, correct and consistent use of condoms(1), and male circumcision.

Conclusive evidence from extensive research among heterosexual couples in which one partner is infected with HIV shows that correct and consistent condom use significantly reduces the risk of HIV transmission from both men to women, and also from women to men(2). Laboratory studies show that male latex condoms are impermeable to infectious agents contained in genital secretions(3). To ensure safety and efficacy, condoms must be manufactured to the highest international standards. They must be procured according to the quality assurance procedures established by the WHO, UNFPA and UNAIDS and they should be stored away from direct heat sources. Prevention programmes need to ensure that high-quality condoms are accessible to those who need them, when they need them, and that people have the knowledge and skills to use them correctly.

Condoms must be readily available universally, either free or at low cost, and promoted in ways that help overcome social and personal obstacles to their use.

Condom use is more likely when people can access them at no cost or at greatly subsidized prices. Effective condom promotion targets not only the general population, but also people at higher risk of HIV exposure, especially women, young people, sex workers and their clients, injecting drug users and men who have sex with men. UNFPA estimates that the current supply of condoms in low- and middle-income countries falls well short of the number required (the condom ‘gap’)(4). Despite the gap, international funding for condom procurement has not increased in recent years. Collective actions at all levels are needed to support efforts of countries, especially those that depend on external assistance for condom procurement, promotion and distribution.

HIV prevention education and condom promotion must overcome the challenges of complex gender and cultural factors.

Young girls and women are regularly and repeatedly denied information about, and access to, condoms. Often they do not have the power to negotiate the use of condoms. In many social contexts, men are resistant to the use of condoms. This needs to be recognized in designing condom promotion programmes. Female condoms can provide women with more control in protecting themselves. However, women will remain highly vulnerable to HIV exposure, until men and women share equal decision-making powers in their interpersonal relationships.

Condoms have played a decisive role in HIV prevention efforts in many countries.

Condoms have helped to reduce HIV infection rates where AIDS has already taken hold, curtailing the broader spread of HIV in settings where the epidemic is still concentrated in specific populations.

Condoms have also encouraged safer sexual behaviour more generally. Recent analysis of the AIDS epidemic in Uganda has confirmed that increased condom use, in conjunction with delay in age of first sexual intercourse and reduction of sexual partners was an important factor in the decline of HIV prevalence in the 1990s(5). Thailand’s efforts to de-stigmatize condoms and its targeted condom promotion for sex workers and their clients dramatically reduced HIV infections in these populations and helped reduce the spread of the epidemic to the general population. A similar policy in Cambodia has helped stabilize national prevalence, while substantially decreasing prevalence among sex workers. In addition, Brazil’s early and vigorous condom promotion among the general population and vulnerable groups has successfully contributed to sustained control of the epidemic.

Increased access to antiretroviral treatment creates the need and the opportunity for accelerated condom promotion.

The success of antiretroviral therapy in industrialized countries in reducing illness and prolonging life can alter the perception of risk associated with HIV(6). A perception of low-risk and a sense of complacency can lead to unprotected sex through reduced or non-consistent condom use. Promotion of correct and consistent condom use within antiretroviral treatment programmes, and within reproductive health and family planning services, is essential to reduce further opportunities for HIV transmission. Rapid scale-up of HIV testing and counselling is needed to meet the prevention needs of all people, whether they are HIV-positive or negative.

1 UNAIDS. 2004 Report on the global AIDS epidemic, page.72.

2 Holmes K, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization. Geneva. June 2004.

3 WHO/UNAIDS. Information note on Effectiveness of Condoms in Preventing Sexually Transmitted Infections including HIV. Geneva. August 2001.

4 UNFPA. 2007 report on donor support for contraceptives and condoms for STI/HIV prevention 2007.

5 Singh S, Darroch J.E, Bankole A. A,B, and C in Uganda: The Roles of Abstinence, Mongamy and Condom Use in HIV Decline. The Alan Guttmacher Institute. Washington DC. 2003.

6 Gremy I, Beltzer N. HIV risk and condom use in the adult heterosexual population in France between 1992 and 2001: return to the starting point? AIDS 2004;18:805-9.

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UNAIDS Executive Director Mr Michel Sidibé (left) with the Prime Minister of Thailand.
Credit: Gov. of Thailand

At the invitation of the Thai Government, UNAIDS Executive Director Mr Michel Sidibé is in Thailand this week to discuss progress in the response to AIDS and visit projects to get a better understanding of how HIV prevention and treatment efforts are making a difference to peoples lives.

Today in Bangkok Mr Sidibé hosted a meeting with civil society partners in the region. In his meeting with national and regional civil society partners, discussions took place on closer collaboration to further the AIDS response.

During his stay Mr Sidibé will meet with the Prime Minister as well as Ministers of Public Health, Interior and Foreign Affairs. Thailand is recognized as a visionary leader in the AIDS response, particularly in scaling up services to prevent the transmission of HIV from mothers to their children. The country also has expertise on HIV counselling and testing and on sexual and reproductive health services for young people which will be one of the topics that Mr Sidibé will be discussing in detail with the Minister of Public Health.

During his country visit to Thailand, UNAIDS Executive Director, Michel Sidibé met with representatives from the Thai and Regional Civil Society, Bangkok, 17 March 2009.
Credit: UNAIDS/P. de Noirmont/Asiaworks

Later in the week Mr Sidibé will visit the seaside resort of Pattaya where an HIV prevention outreach project is aiming to improve the health of the local men, women and transgendered who sell sex to tourists. Pattaya, once a quiet fishing village, is now a magnet for “sex tourism” drawing people from all over the world to buy sex.

Mr Sidibé will conclude his official visit by addressing Asian leaders at the opening of the Asia Pacific Leadership Forum.

This will be Michel Sidibé’s first official visit to Asia since becoming executive director of UNAIDS.

The District of Columbia HIV/AIDS Epidemiology Update 2008 report.

At least 3% of residents in Washington D.C. are living with HIV according to a report published today by US health officials at the District of Columbia's HIV/AIDS Administration.

The leading mode of transmission of HIV in the district is men having sex with men. Heterosexual transmission and injecting drug use closely follow, the report says.

“Today’s findings by US health officials show that there is no room for complacency in responding to HIV,” said Paul de Lay UNAIDS Deputy Executive Director, Programme, ad interim and Director of Evidence, Monitoring and Policy.

“We must continue to learn from each other and work together - both in developing and high-income countries – to ensure universal access to HIV prevention, treatment, care and support services for citizens.”

The District of Columbia HIV/AIDS Epidemiology Update 2008 reports that HIV is found in all demographics in Washington: more than 4% of African-Americans, almost 2% of Latinos and 1.4% of Caucasians are living with HIV. However African-American men are disproportionably affected, accounting for 76% of people living with HIV.

This follows the broader pattern across the United States where racial and ethnic minorities are disproportionately affected by the HIV epidemic. Although African Americans represent about 13% of the population (US Census Bureau, 2006), in 2005 they accounted for 48% of new HIV diagnoses.

The United States of America has one of the largest HIV epidemics in the world, with an estimated 1.2 million people living with HIV in 2007 (UNAIDS, 2008).