What Works for Women and Girls

of a year led to small but significant increases in consistent condom use with all sexualpartners (a declining mean number of unprotected coital acts with all partners from1.7 before female condom introduction to 1.4 after), verified by a biological marker. Sexworkers also stated that they could secretly use the female condom (Thomsen et al.,2006). (Gray III) (female condoms, sexual partners, Kenya)A cost-effectiveness analysis assessed HIV infections averted annually and incrementalcost per HIV infection averted for country-wide distribution of the nitrile female condom(FC2) among sexually active individuals, 15–49 years, with access to publicly distributedcondoms in Brazil and South Africa. In Brazil, expansion of FC2 distribution to 10%of current male condom use would avert an estimated 604 HIV infections at 20,683US dollars per infection averted. In South Africa, 9,577 infections could be averted, at985 US dollars per infection averted. The estimated cost of treating one HIV-infectedindividual is 21,970 US dollars in Brazil and 1,503 US dollars in South Africa, indicatingpotential cost savings. The incremental cost of expanded distribution would be reducedto 8,930 US dollars per infection averted in Brazil and 374 US dollars in South Africaby acquiring FC2s through a global purchasing mechanism and increasing distributionthreefold. Sensitivity analyses show model estimates to be most sensitive to theestimated prevalence of sexually transmitted infections, total sexual activity, and fractionof FC2s properly used. Expanded distribution of FC2 in Brazil and South Africacould avert substantial numbers of HIV infections at little or no net cost to donor orgovernment agencies. FC2 may be a useful and cost-effective supplement to the malecondom for preventing HIV (Dowdy et al., 2006). (Gray III) (female condoms, Brazil,South Africa)A 2007 study of 818 female sex workers in Madagascar for 18 months found that shortand medium term promotion of both male and female condoms increased the totalnumber of protected sex acts and reduced STI prevalence. “This trial provides moderatebut promising evidence of public health benefits gained from adding the femalecondom to male condom distribution” (Hoke et al., 2007: 465). Provision of femalecondoms allows women to “substantially reduce risk of STI acquisition” (Hoke et al.,2007: 465), as STI rates were significantly lower in periods of both male and femalecondom availability. Participants were tested for three different STIs (chlamydia, gonorrheaand trichomoniasis) every six months. Participants received condom promotionand risk reduction counseling delivered by peer educators trained by the study. Sexworkers were counseled to use female condoms only when the male condom could notbe used. Both male and female condoms were available for the same price. Followingsix months of male condom distribution, participants used protection in 78% of sexacts; with the addition of the female condom, protected sex acts increased to 83% attwelve months and 88% at 18 months. STI prevalence declined from a baseline of 52%to 50% with male condoms only at 6 months. With the female condom added, STIprevalence dropped to 41% at month 12 and 40% at month 18 (Hoke et al., 2007). (GrayIII) (female condoms, sex workers, STIs, Madagascar)56 CHAPTER 3 PREVENTION FOR WOMEN