What Works for Women and Girls

Female Condoms Are the Only Female-Initiated HIV Prevention MethodThe female condom is also woefully under-programmed in prevention programs. While attentionis drawn to work on AIDS vaccines and microbicides, in fact, the female condom is the firstHIV prevention technology developed since the beginning of the AIDS epidemic (Brown et al.,2007). In fact, “twenty years into the HIV epidemic, femalecondoms are the only currently available female initiatedmethod of HIV…prevention (Napierala et al., 2008: 121).”Evidence shows that female condom use increasesthe total number of protected sex acts (Vijayakumar et al.,2006) and reduces sexually transmitted infections (Hokeet al., 2007), reducing the risk of HIV acquisition andtransmission. An analysis of five randomized controlledtrials on effectiveness of the female condom found that thefemale condom increased the number of protected sex acts“If you are not equipped,I have mine [female condom].”—Ugandan woman(Green et al., 2001: 596)(Vijayakumar et al., 2006). A systematic review of 237 articles found that ten studies foundlong-term use of the female condom, suggesting that the female condom reaches women lesslikely to use other dual protection methods (Vijayakumar et al., 2006).Increasing Consistent Condom Use in Regular Partnerships Is Key to PreventionPromoting the use of condoms for high-risk sex is an effective approach to reducing HIV transmission,and studies indicate that interventions can achieve high rates of condom use in casualand commercial sex (Bollinger et al., 2004). However, promoting condom use for high-risk sexhas contributed to the association of condom use with illicit sex (Feldman and Masophere,2003), making it more difficult for women to negotiate condom use with regular sexual partners.Condom use among married couples is universally low, and normalizing condom usefor all sex acts, including within marriage, is a challenge (Ali and Cleland, 2005; Hearst andChen, 2004). Despite substantial risk within many primary relationships, condom use is low(Morrison et al., 2009: 265). [See also Chapter 11B. Strengthening the Enabling Environment:Addressing Violence Against Women]Consistent condom use remains largely uncommon among married couples and regularpartners. A review of published literature on patterns of incident infection, risk factors for HIVinfections, and rates of condom use used in regular partnerships found that a large proportionof incident HIV infection in some settings is in regular partnerships. For example, severalepidemiological studies find marriage to be the main risk factor for infections in women. Ananalysis of 23 Demographic and Health Surveys (DHS) from low- and middle-income countriesconducted between 1994 and 2000 found that in eight of the 23 countries, fewer than fivepercent of women aged 15 to 49 used condoms to prevent STIs (Snelling et al., 2006). Marriedwomen particularly find it difficult to discuss condom use with their husbands as doing sotouches on sensitive issues including fidelity and trust (Smith, 2007; Maharaj and Cleland,2004; Nyblade et al., 2003; and Chimbiri, 2007).WHAT WORKS FOR WOMEN AND GIRLS51