Quantcast
home > international > Technical Information > In-depth Program Reviews > Condom Distribution

Program: Condom promotion and distribuion to prevent HIV/AIDS

Print
Email

In a nutshell

  • The Problem: HIV/AIDS is one of the leading killers of adults worldwide. The virus weakens the immune system and ultimately leads to death (more here.)
  • The Program: Condom promotion, through education, counseling and advertising, encourages the use of condoms. Condom distribution makes condoms readily available to individuals either for free or at highly subsidized prices.
  • Track record: Condoms effectively prevent HIV transmission through sexual intercourse. The effectiveness of condom promotion and distribution programs is less clear.
  • Cost-effectiveness: Condom promotion can be highly cost-effective, preventing a case of HIV/AIDS for $550-2,240, but costs vary widely along with the specific type of program implemented.
  • Bottom line: Condom promotion and distribution is likely an effective program at preventing HIV infections, under the right conditions. However, the lack of a strong evidence base for this approach implies that donors should require relatively strong monitoring and evaluation from a charity working on this type of program.

Table of Contents

Basics of the program

What is the program? What problem does it target?

HIV transmission occurs in three ways: (a) sexual intercourse, (b) exposure to infected blood, or (c) mother to child transmission through birth or breast milk.1 Sexual transmission is the primary transmission mechanism worldwide, and accounts for more than 90% of infections in sub-Saharan Africa.2 Condoms can prevent infection by reducing the likelihood of transmission during sexual intercourse. (More about HIV/AIDS here.)

What are the components required to implement this program - how does it work?

  • Promotion. Condom promotion can be conducted in many ways. The most common forms are: (a) advertising in mass media (i.e., television, radio, newspapers); (b) school-based programs, in which students receive HIV/AIDS and condom information in classrooms; and (c) peer-based programs in which individuals are recruited and trained to provide information about HIV/AIDS and condoms to their peers.3
  • Distribution. Condoms may be freely distributed to target high-risk groups (as was the case in Thailand's 100% condom program - see below) or sold at subsidized prices through the private, retail sector (as Population Services International does).

Program track record

Micro evidence: Has this program been rigorously evaluated and shown to work?

There is strong evidence that condoms, when consistently used, reduce the likelihood of transmission. However, there is relatively weaker evidence that condom promotion and distribution programs result in increased condom use and consequently, reduced HIV/AIDS transmission.4

Effectiveness of condoms when used consistently: An analysis was conducted of 14 studies including 4,709 participants. All participants were part of couples where one partner was infected with HIV and the other was not. The review compared cohorts of "always" users of condoms to "never" users and estimated that consistent condom use results in an 80% reduction in HIV incidence.5 Because the reviewed studies are not randomized controlled trials, the authors note that other factors may have caused the observed reduction in HIV transmission rates. Factors may have included (a) frequency of sexual activity (b) the fact that condom users are self-selected, which introduces other, unknown biases, or (c) rates of other risky behaviors, like drug use.6

Effectiveness of condom promotion and distribution programs. The Disease Control Priorities Report lists 11 individual studies that resulted in increased condom use or reductions in HIV transmission.7 10 of 11 studies found increased condom use and two of three (which measured HIV incidence) found reduced incidence.8 However, (a) many of these studies were not randomized controlled trials; (b) they often ran programs (e.g., one-on-one counseling about sexual behavior for study subjects every 3 months as seen in the Bentley 1998 study) that are not necessarily representative of programs implemented by NGOs more broadly; (c) many rely on self-reported condom use information; (d) many are focused on highly-specific groups of people (such as sex workers, featured in 5 of the 11 studies listed by the DCP) or means of provision (such as provision directly in motel rooms, as seen in the Egger 2000 study).

More on our interpretation of "micro evidence" and evaluation quality here.

Macro evidence: Has this program played a role in large-scale success stories?

Condom promotion and distribution has been credited with a number of large-scale, successful programs in the developing world to control HIV/AIDS. Below we summarize reports on Thailand (Levine 2007) and Uganda (WHO).

  • Thailand: In 1991, Thailand implemented a nationwide condom program aiming for 100% condom use in sexual encounters with sex workers.9 According to Levine 2007, the program provided condoms free of charge, provided education and promotion of condoms, and carefully monitored incidences of sexually transmitted infections to identify locations that weren't in compliance with the initiative.10 Sexually transmitted infections fell significantly and reported condom use rates rose rapidly in response to the program.11
  • Uganda: Uganda experienced a significant decline in HIV infection rates after implementing a national HIV program.12 Although we have few specifics about the program itself, we know that in addition to condom promotion and distribution, the programs consisted of (a) "sex education programmes in schools and on the radio"; (b) a "social marketing scheme involving sales of condoms at subsidized prices or free distribution by both the government and the private sector"; (c) "condom use promotion among men who seek treatment for sexually transmitted infections"; and (d) "the launch in 1997 of same-day voluntary counselling and testing services."13

Recommendations and concerns

Do expert reviews of the comparative merits of interventions endorse this one?

See this page for sources consulted.

  • The Disease Control Priorities Report concludes that resources should be devoted to HIV prevention and care due to the "the magnitude and seriousness of the global pandemic."14 Nevertheless, the report doesn't strongly endorse this intervention in particular, stating "In the absence of firm data to guide program objectives, national strategies may not accurately reflect the priorities dictated by the particular epidemic profile, resulting in highly inefficient investments in HIV/AIDS prevention and care."15
  • The Copenhagen Consensus ranks "HIV Combination Package" as its 19th most cost-effective intervention.16
  • Jamison 2008 ranks "HIV: combination prevention" as it's 6th most cost-effective intervention to prevent disease, lower than DOTS and malaria treatment and prevention, including provision of ITNs.17

What are the potential downsides of the intervention?

It is possible that increased condom promotion and distribution could lead to increased sex frequency and an increase in high-risk sexual activities. The Disease Control Priorities Report raises this concern and states that available data suggest that, "Sex education, including condom promotion, does not encourage or increase sexual activity (Kirby 2001)."18

Cost-effectiveness

The Disease Control Priorities Report estimates costs at $52-$112 per disability-adjusted life-year (DALY) averted for this program type.19 This makes it a reasonably cost-effective program.20 (More on the DALY metric here.) Note that Population Services International estimates substantially lower costs per DALY for its own condom distribution programs, using what we find to be a relatively plausible methodology (details here).

Using a simple conversion calculation,21 we estimate that $52-$112 per DALY averted is equivalent to $1,020-$2,240 per HIV infection averted, while PSI's estimate comes in lower at ~$550 per HIV infection averted.

Sources

  1. 1.

    "HIV transmission predominantly occurs through three mechanisms: sexual transmission, exposure to infected blood or blood products, or perinatal transmission (including breastfeeding)." DCP 2006, Pg 333

  2. 2.

    "Worldwide, sexual intercourse is the predominant mode of transmission, accounting for approximately 80 percent of infections (Askew and Berer 2003). Sexual intercourse accounts for more than 90 percent of infections in Sub-Saharan Africa. Although many people who know they are infected reduce their risk behaviors, studies in developed countries suggest that a substantial percentage nevertheless continue to engage in unprotected sex". DCP 2006, Pg 334

  3. 3.

    DCP 2006, Pg 334

  4. 4.

    "Given the central role that condom promotion, distribution, and social marketing has played in HIV prevention programs, the lack of data on the relative cost-effectiveness of such programs 20 years into their implementation is striking. It is beyond dispute that the use of a condom by sexual partners who are HIV-discordant is extraordinarily cost-effective, given the low cost and high effectiveness of the condom in preventing HIV transmission. Information on the relative costs and effectiveness of different approaches to increasing condom use by serodiscordant sexual partners is not available,with the shortage of information being far more acute for effectiveness than for costs. In the absence of empirical evidence, decision makers are reduced to formulating policy on the basis of theory and common sense." DCP 2006, Pg 345

  5. 5.

    Weller 2002, Pgs 1-2

  6. 6.

    "The lack of random assignment of individuals to use or not use condoms can result in an unequal distribution of HIV risk factors across those categories and can bias estimates of condom effectiveness. Factors associated with both seroconversion and condom use can bias estimates of condom effectiveness. Differences between “always” and “never” users in duration and frequency of exposure or in infectivity and susceptibility can bias estimates. Because condom use is associated with HIV risk factors, the association between condom use and seroconversion is biased by the self-selection of individuals into the always and never condom usage groups. Notably, condom non-users in recent studies may be more likely to be IDUs (Padian 1997) and may be more likely to engage in other risky behaviors (Skurnick 1998; Kennedy 1993; Pinkerton 1995; Ross 1988). Higher HIV transmission among partners of IDUs (Padian 1997) and a preponderance of partners of IDUindex cases among condom non-users, can inflate incidence estimates for condom nonusers and result in an overestimation of condom effectiveness." Weller 2002, Pg 3

  7. 7.

    DCP 2006, Pg 337

  8. 8.

    DCP 2006, Pgs 337-8

  9. 9.

    Levine 2007, Case 2, Pg 1

  10. 10.

    "Health officials provided boxes of condoms free of charge, and local police held meetings with sex establishment owners and sex workers, despite the illegality of prostitution. Men seeking treatment for sexually transmitted infections (STIs) were asked to name the sex establishment they had used, and health officials would then visit the establishment to provide more information." Levine 2007, Case 2, Pg 1

  11. 11.

    Levine 2007, Case 2, Pg 3

  12. 12.

    According to the WHO, "Since 1993, HIV infection rates among pregnant women, a key indicator of the progress of the epidemic, have been more than halved in some areas and infection rates among men seeking treatment for sexually transmitted infections have dropped by over a third... In the capital city Kampala, the level of HIV infection among pregnant women attending antenatal clinics fell from 31% in 1993 to 14% by 1998. Meanwhile, outside Kampala, infection rates among pregnant women under 20 dropped from 21% in 1990 to 8% in 1998. Elsewhere, among men attending STI clinics, HIV infection rates fell from 46% in 1992 to 30% in 1998." WHO Success Stories in Developing Countries: Uganda Reverses the tide of HIV/AIDS

  13. 13.

    WHO Success Stories in Developing Countries: Uganda Reverses the tide of HIV/AIDS

  14. 14.

    DCP 2006, Pg 361

  15. 15.

    DCP 2006, Pg 361

  16. 16.

    Copenhagen Consensus 2008

  17. 17.

    Jamison et al. 2008, Pg 51

  18. 18.

    DCP 2006, Pg 344

  19. 19.

    DCP 2006, Pg 74.

  20. 20.

    DCP 2006, Figures 2.2 and 2.3, Pgs 41-42, for a chart of the cost-effectiveness range (measured in cost per DALY) for many programs.

  21. 21.

    20 DALYs per infection averted: "The estimates of cost per disability-adjusted life year (DALY) saved assume a uniform 20 DALYs lost per infected adult (Murray and Lopez 1996) and 25 DALYs lost per infected child (Marseille and others 1999) and do not account for the increasing proportion of people living with HIV/AIDS in developing countries who will have access to antiretroviral therapy over the coming years." DCP page 344. Note that we assume all prevented HIV infections are among adults; see Williams et al., "Measuring age-specific HIV-incidence. comparing estimates based on detuned ELISA and age-specific prevalence." in Int Conf Aids. 2000 July 9-14, available online at http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102242652.html, accessed 6/30/09.

Clicky Web Analytics