Availability of condoms in urban and rural areas of KwaZulu-Natal, South Africa

Giving condoms to school children: educators' views on making condoms available in South African schools

One of the policy goals of the South African Department of Basic Education's National Policy on HIV, STIs and TB of 2017 is to reduce the incidence of HIV and pregnancy among learners. This is expected to be achieved by improving access to prevention services, including the provision of condoms in schools. This study uses street- level bureaucracy theory to explain how educators can play a more productive role in ensuring that policy goals are achieved. Educators provide their views on their role as condom promotion agents, their perception of demand and utilisation among learners, as well as their insights on suitable distribution mechanisms in the school setting. Trepidation exists among educators about their roles in the promotion and education of condoms. Educator statements suggest that they see the value in their policy-ascribed role to deliver sexual health messages and are also open to performing a role in the distribution of condoms at schools. However, our findings reveal that their role as policy communicators or "street-level bureaucrats" is complicated by inadequate policy guidance. We therefore conclude that to achieve optimal outcomes in terms of safer sexual practices among learners, condom messaging and distribution mechanisms in school settings require evidence-informed implementation strategies.

Youth underrepresentation as a barrier to sexual and reproductive healthcare access in Kasulu district, Tanzania: A qualitative thematic analysis

OBJECTIVES

Representation of the key groups in community-level healthcare decisions is a prerequisite for accountable and responsive primary healthcare systems. However, meaningful representation requires both the presence of individuals who represent the key community groups and their capacity to influence the key healthcare plans and decisions. Our study explored how the underrepresentation of the youth in health facility committees, the decentralized community- and facility-level healthcare decision-making forums affects youth access to sexual and reproductive health services.

METHODS

A multisite case study involving focus group discussions, interviews, and meeting observation was conducted in eight primary healthcare facilities in Kasulu, a rural district in Tanzania. Inductive thematic analysis was used to identify the key emerging themes.

RESULTS

Five major themes were identified in connection with youth underrepresentation and limited access to sexual reproductive health as a 'taboo' phenomenon in the communities. These were: numbers do not matter, passive representation, sociopolitical gerontocracy, economic vulnerability, and mistrust and suspicion.

CONCLUSIONS

Gradual emancipatory and transformative efforts are needed to normalize the representation of the youth and their concerns in formal community-level decision-making institutions.

Geospatial analysis of condom availability and accessibility in urban Malawi

Prevalence of HIV in sub-Saharan African countries persists at alarming rates. There are currently four promoted methods to prevent HIV infection: adherence to antiretroviral therapy, male circumcision, pre-exposure prophylaxis and use of condoms. This study aimed to assess the availability and accessibility of one of the prevention efforts, condoms, in Kawale, Lilongwe, Malawi. A total of 220 potential condom-selling establishments were surveyed in 2012. Data were collected with store owners or staff and locations were geocoded to assess store density. Descriptive analyses were conducted. Of those audited, 96 stores sold condoms, 13 of which distributed free condoms. The stores were most often small shops and located in markets or trading centres. Condoms were most often found at the back of the store in an open space. There were approximately 1.2 stores per ¼ mile; 44% of the businesses in the study region carried condoms. This one method of prevention exhibited multiple barriers in this region: few stores sold condoms, high costs, condom locations within stores and limited availability. The limited accessibility is likely to influence social norms surrounding condom use. Future research should incorporate assessing norms and addressing barriers to uptake of HIV prevention efforts.

Low adverse event rates following voluntary medical male circumcision in a high HIV disease burden public sector prevention programme in South Africa

INTRODUCTION

The provision of voluntary medical male circumcision (VMMC) services was piloted in three public sector facilities in a high HIV disease burden, low circumcision rate province in South Africa to inform policy and operational guidance for scale-up of the service for HIV prevention. We report on adverse events (AEs) experienced by clients following the circumcision procedure.

METHODS

Prospective recruitment of HIV-negative males aged 12 and older volunteering to be circumcised at three select public health facilities in KwaZulu-Natal between November 2010 and May 2011. Volunteers underwent standardized medical screening including a physical assessment prior to the surgical procedure being performed. AEs were monitored at three time intervals over a 21-day period post-operatively to determine safety outcomes in this pilot demonstration programme.

RESULTS

A total of 602 volunteers participated in this study. The median age of the volunteers was 22 years (range 12-56). Most participants (75.6%) returned for the 48-hour post-operative visit; 51.0% for day seven visit and 26.1% for the 21st day visit. Participants aged 20-24 were most likely to return. The AE rate was 0.2% intra-operatively. The frequency of moderate AEs was 0.7, 0.3 and 0.6% at 2-, 7- and 21-day visits, respectively. The frequency of severe AEs was 0.4, 0.3 and 0.6% at 2-, 7- and 21-day visits, respectively. Swelling and wound infection were the most common AEs with mean appearance duration of seven days. Clients aged between 35 and 56 years presented with most AEs (3.0%).

CONCLUSIONS

VMMC can be delivered safely at resource-limited settings. The intensive three-visit post-operative review practice may be unfeasible due to high attrition rates over time, particularly amongst older men.

Condom accessibility: the moderating effects of alcohol use and erotophobia in the information-motivation-behavioral skills model

OBJECTIVE

The information-motivation-behavioral skills model was used to investigate which factors were associated with condom accessibility among undergraduate college aged adults. Our aim was to also examine moderating effects of erotophobia/erotophilia and alcohol use, as these have been related to sexual risk and prevention behaviors among young adults.

METHOD

Participants completed survey questionnaires on personal computers.

RESULTS

Support was found for the paths of the information-motivation-behavioral skills model. Alcohol use moderated the mediating effect of behavioral skills between motivation and condom accessibility, and erotophobia/erotophilia moderated the effect of motivation and behavioral skills on condom accessibility. Higher alcohol use was associated with a lower likelihood of having condoms accessible, and individuals with higher levels of erotophobia had weaker paths between motivation and behavioral skills than those with lower levels.

DISCUSSION

Discussion centers on the role of individual differences on protective behaviors that require planning and how intervention efforts can be tailored to promote these changes.

Lot quality assurance sampling for monitoring coverage and quality of a targeted condom social marketing programme in traditional and non-traditional outlets in India

Objectives

This study reports on the results of a large-scale targeted condom social marketing campaign in and around areas where female sex workers are present. The paper also describes the method that was used for the routine monitoring of condom availability in these sites.

Methods

The lot quality assurance sampling (LQAS) method was used for the assessment of the geographical coverage and quality of coverage of condoms in target areas in four states and along selected national highways in India, as part of Avahan, the India AIDS initiative.

Results

A significant general increase in condom availability was observed in the intervention area between 2005 and 2008. High coverage rates were gradually achieved through an extensive network of pharmacies and particularly of non-traditional outlets, whereas traditional outlets were instrumental in providing large volumes of condoms.

Conclusion

LQAS is seen as a valuable tool for the routine monitoring of the geographical coverage and of the quality of delivery systems of condoms and of health products and services in general. With a relatively small sample size, easy data collection procedures and simple analytical methods, it was possible to inform decision-makers regularly on progress towards coverage targets.

Correlates of intention to use condoms among Sub-Saharan African youth: the applicability of the theory of planned behaviour

AIMS

To test the applicability of an extended version of the theory of planned behaviour for the study of condom use intentions among large samples of young people in South Africa and Tanzania.

METHODS

Baseline data of a randomized controlled trial of school-based HIV/AIDS prevention programmes were used. The setting comprised secondary schools in the regions of Cape Town, Polokwane and Dar es Salaam. Participants were 15,782 secondary school students. The main measures were scales for intentions, knowledge, risk perceptions, attitudes, perceived social norms and perceived self-efficacy regarding condom use.

RESULTS

Seven variables accounted for 77% of the variance in intentions to use condoms: attitudes (beta = 0.17), injunctive norms (beta = 0.27), self-efficacy (beta = 0.41), gender (lower condom use intentions among females), being a student at the Dar es Salaam site (lower scores than students in Cape Town and Polokwane), socioeconomic status (higher intentions with higher status), and access to condoms (higher intentions with higher access).

CONCLUSIONS

Our results are comparable to those of studies conducted in Europe and the USA. Social cognition models such as the theory of planned behaviour are applicable in understanding the correlates of condom use intentions in African contexts.

Condom access in South African schools: law, policy, and practice

Juliana Han and Michael L. Bennish discuss their experience developing a policy on condom distribution for Mpilonhle, a South African nongovernmental organization involved in HIV prevention in schools.

Microbicide acceptability: insights for future directions from providers and policy makers

To help fill the gap concerning health care providers' and policy makers' knowledge of and views concerning microbicides, we compared data from one U.S. study and two South African studies that explored these issues. Frontline providers in South Africa were enthusiastic about any method that would have the potential to slow the HIV/AIDS epidemic, whereas providers in New York City and policy makers in South Africa balanced their enthusiasm with more concerns. Across all studies, participants wanted timely and accurate scientific information, and they raised issues about safety, "messiness," and cost. Many had difficulty understanding that promoting a partially effective method can reduce risk if a client uses it more often than a highly effective method. Microbicide advocates need to effectively communicate to providers the evidence-based findings from microbicide trials and find approaches to introduce concepts such as "harm reduction" and "prevention equation" perspectives in client counseling. Developing these approaches will maximize the positive influence that providers can exert on user acceptability of microbicides once they become available.

HIV/AIDS/STD Knowledge, Attitudes, Beliefs and Behaviours in a Rural South African Adult Population

The aim of the study was to evaluate data on behavioural indicators in relation to HIV/AIDS/STD prevention and occurrence in a rural adult population in South Africa. A representative community sample of adults (n=398) using a three-stage cluster sampling method was chosen for a household survey, and qualitative data were obtained from adults using ten focus group discussions. The survey sample included 398 adults: 155 (38.9%) male and 243 (61.1%) female, whose ages ranged from 25 to 49 years ( M=37.1 years, SD=12.6). The questionnaire included 71 items on HIV-related knowledge, attitudes, beliefs and behaviours. The results indicated a mean HIV/AIDS knowledge score of 6.77 (range: 0 to 9), indicating a moderately adequate knowledge. HIV/AIDS knowledge was identified as a predictor for HIV-risk behaviour. Forty-six percent of the men and 21.4% of the women indicated that they had had a non-regular sexual partner in the last 12 months, and 53.4% of the women and 45.6% men said that they had never used a condom with their non-regular, non-commercial partner during the preceding 12 months. Among female adult women, 15.4% reported having been victims of enforced sex during the last 12 months. There was a high incidence of self-reported genital discharge/ulcers/sores within the preceding 12 months among the participants (19.7% in men and 11% in women). The study's findings are discussed in relation to implications for health education.

Improving the accessibility of condoms in South Africa: the role of informal distribution

Lack of access to condoms presents a fundamental barrier to HIV prevention across most of sub-Saharan Africa. One strategy to enhance the accessibility of condoms is to promote their informal distribution outside of health facilities through existing social networks. To investigate the prevalence and practices of informal condom distribution, we administered a questionnaire to individuals procuring condoms at 12 public health facilities in four regions of South Africa. Of the 554 individuals interviewed, 269 (48%) reported either giving or receiving condoms informally in the month before the study. In multivariate analysis, reporting informal condom distribution was associated with increased education, male gender, multiple sex partners and recent condom use. The specific practices involved in giving or receiving condoms differed between males and females, with women more likely to involve family members and men more likely to involve friends. These results indicate that informal condom distribution is surprisingly common among individuals procuring public sector condoms in South Africa, and begin to suggest the gendered nature of informal condom distribution networks. While these findings require confirmation in other populations, the practices of informal condom distribution described here provide an excellent opportunity for enhancing condom accessibility and delivering other interventions for HIV prevention.

The fate of free male condoms distributed to the public in South Africa

OBJECTIVES

Public sector male condom distribution in South Africa rose from six million in 1994 to 198 million in 1999 as part of the government's condom promotion efforts for HIV/AIDS prevention. This study investigates what happens to the condoms which are distributed free of charge by the South African Department of Health.

METHODS

A prospective study was undertaken during 1998-1999 at 12 representative public health facilities. Five-hundred and fifty-four consecutive subjects leaving the facilities were recruited and followed-up for 5 weeks to ascertain the fate of the 8164 condoms they had procured.

RESULTS

A total of 384 participants (69.3%) and their 5528 condoms (67.7%) were followed successfully. After 5 weeks, 43.7% of the condoms had been used or broken in sex, 21.8% had been given away, 8.5% had been lost or discarded, and 26.0% were still available for use. Increased rates of condom use by participants were associated with active (compared to passive) condom procurement.

CONCLUSIONS

In light of the rapidly increasing number of free condoms being distributed by the public health service in South Africa, it is reassuring to note that wastage at 5 weeks is less than 10%. Extrapolating these data to the 198 million public sector condoms distributed in South Africa in 1999, at least 87 million condoms were used in sex. This methodology may be used to help evaluate the impact of existing condom distribution systems and the effectiveness of various condom promotion strategies.