University College Cork

Department of Epidemiology and Public Health

Student Name: Audrey Fratus

Student Number: 118106775

Title of Assignment: Essay Title #3 – Intervention Analysis

Module Code: EH2008

I declare that the content of this assignment is all

my own work. Where the work of others has been
used to augment my assignment it has been
referenced accordingly.

Signed ______________________ Date: 30/11/2018

Word Count: 2239

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Analysis of the Provision of Condoms as an HIV Prevention

Initiative

Module EH2008
Title Essay Title #3 – Intervention Analysis
Name and Student # Audrey Fratus - 118106775
Student Status Visiting Student
Date of Submission 30 November 2018
Word Count 2,239
Referencing System APA
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Analysis of the Provision of Condoms as an HIV Prevention Initiative

In the early stages of HIV awareness, prior to the development and widespread use of
antiretroviral (ARV) therapy to control the condition and reduce its rate of transmission, primary
prevention in the form of abstinence, partner reduction, and condom-use played a vital role in
controlling the spread of the epidemic. As improvements in medical treatment were made,
testing became easier and more accessible, and the public health and medical communities
developed a stronger understanding of HIVs biological makeup and means of transmission,
condom use as a means of HIV prevention became less intensely emphasized and rates of use of
physical barrier methods during all forms of sexual contact declined. In the modern age of HIV
management and reduction, promotion of condoms to target populations has failed to maintain
roots in most formal health systems, though there is strong evidence of their effectiveness in
preventing the transmission of HIV. (Foss, Watts, Vickerman, & Heise, 2004) This lack of focus
on an effective method of primary prevention can be attributed to several key weaknesses in the
standard methods of implementing condom use as an HIV intervention, as well as political,
social, and medical bias against their use. In addition, major health institutions such as the
International AIDS Conference and the WHO have shifted attention and resources towards other
HIV control initiatives, causing national and local organizations to follow suit. (Feldblum,
Welsh, & Steiner, 2003) While global rates of new HIV infections have declined 18% since
2010, the rate of decline has stagnated from 2016 to 2018. (“HIV Prevention Programmes
Overview”, 2017) This stagnation, and the strong possibility that the world will not meet its 2020
goals for rate reduction and treatment established by the United Nations Programme on
HIV/AIDS, indicates that a reassessment of the current approach to HIV management is needed.
(“HIV Prevention Programmes Overview”, 2017) Analyzing the strengths and weaknesses of
global condom provision as a primary prevention initiative and placing that initiative within the
broader context of health promotion provides a key example of the need for adaptation and
sustainability when developing and implementing health programs and policies.
Condom use is well-established as a means of reducing the risk of STI transmission when
used consistently and correctly. In studies of couples where one partner was HIV-positive and
one was not, consistent condom use was 90% effective at preventing transmission, lowering the
risk of sexual transmission of HIV from 1 transmission in every 500 exposures to 1 in every
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5000 exposures. (Foss, Watts, Vickerman, & Heise, 2003) In addition, the US NIH and the
WHO found that condoms were “essentially impermeable” to HIV, reducing concerns that latex
condoms might not provide sufficient barrier against microscopic pathogens. (United Nations
Programme on HIV/AIDS, 2004) Case studies conducted in Southeast Asia, Sub-Saharan Africa
and Brazil among high-risk populations found that as condom use in those populations increased,
their rates of HIV diagnosis decreased to a significant enough degree that causation, rather than
simple correlation, can be assumed. (United Nations Programme on HIV/AIDS, 2004) The
combination of large-scale public health research, laboratory verification, and case study analysis
indicates that condoms perform well as a method of preventing new cases of HIV, and as a result
reduce morbidity and mortality as a result of HIV/AIDS.
In addition to being effective at preventing transmission, condom promotion as a health
initiative is also highly cost effective. Population Services International, a company that handles
global condom distribution, estimates that the total production and distribution cost of each
condom they sell is $0.12 (Feldblum, Welsh, & Steiner, 2003) Analysis of the cost of treatment
and the social impact of an at-risk or HIV+ individual being treated with ARV therapy has
indicated that condoms are at least 2 times more cost effective than other standard interventions.
(Feldblum, Welsh, & Steiner, 2003) Given the fact that ARV medication costs (at absolute
minimum) $1 a day to produce, and substantially more to purchase in most health systems, it’s
clear that condoms are far more financially accessible while providing similar impact on the rate
of transmission.
Despite the medical and financial effectiveness of the initiative to provide and promote
condoms as a form of primary prevention of HIV, the current approach to condom provision is
not without its weaknesses. A central failure of the initiative is to provide high-quality,
conclusive evidence of effectiveness in a range of settings and populations. A 2017 review of
available research on the impact of Condom Distribution Initiatives (CDIs) on sexual health
behavior found that most current research conducted in the United States on the subject is deeply
flawed, with heavy bias and minimal focus on biological markers of health and wellbeing. The
researchers conducting the review were unable to draw any meaningful conclusions from the
research they reviewed, compelling them to conclude that while it could be proved that condoms
are 65-90% effective at reducing the rate of transmission of HIV, it is impossible to prove that
condom use contributes to healthier sexual decision-making overall. (Malekinejad, Parriott,
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Blodgett Et Al, 2017) In addition, the current evidence used by CDIs to indicate effectiveness in
HIV control is often limited in scope, focusing only on heterosexual couples, sex workers, or
residents of a highly specific region or geographic community. (Malekinejad, Parriott, Blodgett
Et Al, 2017) While condoms were highly effective at lowering incidence of HIV in all those
cases, that research cannot be unquestionably transferred onto populations as a whole. In
addition, while they uniformly conclude that condoms should be used, many studies into the use
of condoms to prevent the spread of HIV have been contradictory in their data, which weakens
the body of research. As Archibald Cochrane established in Evidence and Efficiency, ensuring
that an intervention (whether it be at the individual level of medical treatment or in the broader
public health field) is supported by well-constructed research into the intervention’s
effectiveness and the possibility of other approaches helps to guarantee that the target of the
intervention does not undergo behavioral or medical change without positive results. (Shah &
Chung, 2009) Cochrane’s evidence-based model is now the norm when assessing health
interventions and promotion initiatives. CDIs are supported by a large body of research, but not
research which is high quality and highly applicable to the large populations targeted by the
initiatives. Investment by public health organizations and academic institutions into bolstering
the quality of evidence would enable CDIs to be more compelling when appealing for funding
and formal recognition and cooperation from governments and communities.
Condom provision initiatives often fail to address ingrained community bias against
condom use, resulting in poor adherence to their use. Research conducted by the WHO found
that only using condoms occasionally resulted in near-identical rates of transmission of HIV as
never using condoms, and recommended that promotion initiatives emphasize the vitality of
using a condom during every sexual encounter without fail. (HIV Prevention Coalition, 2017)
While many condom initiatives have attempted to follow this recommendation, they have often
come up against strong opposition from community members and low follow through from
medical providers. In a case study conducted in Ghana, it was found that doctors only
recommended future condom use to men presenting with STI symptoms 6% of the time.
(Feldblum, Welsh, & Steiner, 2003) Religious objection to contraceptives has also reduced the
effectiveness of CDI’s, causing a spike in spousal transmission of HIV in certain communities.
The initiatives are often ill-equipped to address social norms and traditional sexual behavior, and
they frequently fail to take religious, financial, and cultural needs into account. A review of
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condom provision in South Africa – where HIV rates have continued to rise - found that many
people in the low-income communities surrounding Johannesburg and Cape Town could not
afford to regularly purchase condoms, but were ashamed of being seen entering a sexual health
clinic or community outreach center to access the free condoms provided by those organizations.
In addition, some respondents cited age and lack of reliable transportation as obstacles to
accessing CDI services. (Malekinejad, Parriott, Blodgett Et Al, 2017) Social stigma often hinders
condom use, with individuals citing the belief that requesting to use a condom would indicate
that there was “something wrong” with them or their partner, or that it would make sexual
contact uncomfortable or un-pleasurable. (Van Rossem & Meekers, 2011) Mere provision is not
sufficient if it does not take the social needs of the target populations into account.
With those challenges in mind, it’s important to acknowledge the intersections between
the provision of condoms as a mode of HIV control and health promotion theory. In a general
review of the Center for Disease Control’s recommendations for HIV control in the United
States, and of the international HIV-focused CDIs who base their work on those
recommendations, it’s clear that social determinants of health are often neglected when
developing condom promotion initiatives. For example, the NYC Condom Availability Program
(NYCAP) was established by the city government of New York, NY as a response to the
HIV/AIDS epidemic and under the guidance of the CDC. The program distributes upwards of 38
million condoms annually to 3500 businesses, hospitals, and community-based organizations in
all boroughs of New York City. (“NYC Condoms”, n.d.) In addition, NYCAP follows the CDC-
recommended approach to condom promotion, which focuses on provision of information on
HIV prevention to target demographics. (“Condoms for HIV Prevention”, 2009) While their
work is undeniably widespread and physically accessible, they focus exclusively on the
individual-level choice to use a condom during all sexual contact. Using the oft-cited Dahlgren
and Whitehead model, a health promotor can look beyond that individual behavioral level of
promotion to the social, economic, and environmental factors that may help or hinder the target
populations of HIV-oriented CDIs to make a healthy choice regarding condom use. (Dahlgren &
Whitehead, 1991) As discussed, religious belief, financial insecurity, poor medical advice, or
concerns about judgement from a partner or a community all limit the efficacy of CDIs. Making
a service “available” is by no means effectively implementing the service, and in today’s health
promotion community, it’s clear that provision of information (i.e. just telling a target population
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what choices they should make) is not sufficient action, as it does not mitigate the impact of
structural barriers to good health.
HIV-oriented CDIs have close links to the key action areas of health promotion, as
defined by the 1986 Ottawa Charter, and engage with those action areas to varying degrees of
depth and success. In the modern era of HIV prevention, public policy and health system
changes are increasingly vital. Currently, the majority of funding and implementation resources
for CDIs is provided by international or supranational organizations like the WHO. (HIV
Prevention Coalition, 2017) While many domestic governments have HIV/AIDS-related policies
or goals, few directly fund and support CDIs as a form of primary prevention, choosing to
instead rely on NGOs or UN intervention. Therefore, the projects are often beholden to
international support, which can delay shipments, increase costs, reduce cultural and political
awareness, and may lead to inconsistent product provision due to sudden changes in
organizational focus or funding. (HIV Prevention Coalition, 2017) Indeed, in the past 10 years
there has been a substantial decrease to the funding available for CDIs, due in part to the United
States’ substantial reduction in funding allocated to international sexual health interventions and
organizations. Domestic governments of nations struggling with high rates of HIV have not
generally responded to this loss of funding with public policy designed to “take up the slack” and
maintain CDIs, causing many organizations administering condom distribution programs to shift
focus to advocating for improved health policy from the countries in which they operate. (HIV
Prevention Coalition, 2017) Along that vein, HIV prevention advocates have long fought for
local health services to promote condom use to their patients regardless of age, marital status, or
religion. Specifically, some CDIs have turned to community health nurses, who frequently do
home visits and lead neighborhood meetings, to discuss using condoms with the individuals they
care for. Their intervention can be vital, as they are more likely to have direct access to high-risk
populations, and more likely to understand the cultural obstacles to condom use. (HIV
Prevention Coalition, 2017)
However, top-down programming from government officials or healthcare providers is
not sufficient, and HIV-oriented CDIs are increasingly community-based to ensure that a high
level of equity and self-determination is maintained. In CDIs targeting secondary schools and
universities, condom promotion is often placed in the hands of peer leaders in attendance at the
partner schools, and in programs centered in the gay community, LGBT+ centers and community
 8

members take primary responsibility for education and practical distribution. (“Community
Based Distribution of Condoms”, 1995) The latter approach is particularly vital in areas where
gay men may still face violence or social rejection, as it helps to ensure that they have access to
safe spaces to receive sexual health information without additional concerns about their
wellbeing. However, if a body of evidence grows to indicate that most people’s choices are more
heavily influenced by family rather than their peers, CDIs may have to alter their tactics to
ensure that their programming is effective.
The provision of condoms as a method of primary HIV prevention is by no means a new
or revolutionary initiative, but in order for it to maintain a high level of efficacy, it needs to fully
embrace the current standards of health promotion by engaging closely with communities,
governments, and health systems to ensure equity and sustainability. In addition, the initiative
could allow for deeper, more meaningful promotion of sexual well-being by connecting more
fully with determinants of health beyond the level of individual behavior. There is substantial
evidence that condoms remain one of the easiest, most effective, and most financially sound
methods of managing the spread of HIV, and actively pushing the initiative to become more
comprehensive and more attuned to the goals and values of health promotion would allow it to
regain a position as a leading component of the prevention of HIV transmission worldwide.
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Works Cited
Community-Based Distribution of Contraceptives – World Health Organization. (1995).
Retrieved from
http://www.who.int/reproductivehealth/publications/family_planning/9241544759/en/
Condoms for HIV Prevention - World Health Organization. (2009, March 25). Retrieved from
http://www.who.int/hiv/topics/condoms/en/
Feldblum, P. J., Welsh, M. J., & Steiner, M. J. (2003). Don't Overlook Condoms for HIV
Prevention. Journal of Sexually Transmitted Infections,79, 267. doi:10.1136/sti.79.4.267
Foss, A. M., Watts, C. H., Vickerman, P., & Heise, L. (2004). Condoms and prevention of
HIV. BMJ (Clinical research ed.), 329(7459), 185-6.
HIV Prevention Coalition – UNAIDS. (2017, July). Strengthening HIV Primary Prevention: Five
Thematic Discussion Papers to Inform Country Consultations and the Development of a
Global HIV Prevention Roadmap. Retrieved from
https://hivpreventioncoalition.unaids.org/wp-content/uploads/2018/01/Discussion-papers-
29-Sep.pdf
HIV Prevention Programmes Overview - AVERT. (2017, August 30). Retrieved from
https://www.avert.org/professionals/hiv-programming/prevention/overview#Intervention
approaches
Malekinejad M, Parriott A, Blodgett JC, Horvath H, Shrestha RK, Hutchinson AB, et al. (2017)
Effectiveness of community-based condom distribution interventions to prevent HIV in
the United States: A systematic review and metaanalysis. PLoS ONE 12(8): e0180718.
https://doi. org/10.1371/journal.pone.0180718
NYC Condoms - New York City Health Department. (n.d.). Retrieved from
https://www1.nyc.gov/site/doh/health/health-topics/condom.page
Shah, H. M., & Chung, K. C. (2009). Archie Cochrane and his vision for evidence-based
medicine. Plastic and reconstructive surgery, 124(3), 982-8.
United Nations Programme on HIV/AIDS. (2004). United Nations Best Practice Collection:
Making Condoms Work for HIV Prevention. UNAIDS/04.32E. Retrieved from
http://data.unaids.org/publications/irc-pub06/jc941-cuttingedge_en.pdf
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Van Rossem, R., & Meekers, D. (2011). Perceived social approval and condom use with casual
partners among youth in urban Cameroon. BMC public health, 11, 632.
doi:10.1186/1471-2458-11-632