There is a pervasive pattern of stockouts of condoms, both male and female condoms, in African countries confronting HIV/AIDS, according to Carolyn Ryan, MD, MPH, director of technical leadership at the Office of the Global AIDS Coordinator (OGAC).
She called the condom gap “really quite disturbing,” given that condoms are a crucial tool for HIV prevention. While HIV incidence has fallen in recent years, in 2009 there were an estimated 2.6 million people newly infected with HIV, meaning that about 7000 people are acquiring the infection each day.
She made her comments at the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Scientific Advisory Board meeting in early January. Many of the slides delivered at this meeting have now been made public on the PEPFAR website, including the presentation by Ryan on prevention and one by Dr. Charles Holmes on care and treatment, including prevention of mother-to-child transmission (PMTCT) of HIV.
Ryan said that OGAC surveyed a number of high HIV prevalence African countries and found that in nine out of 10 there were persistent, sector-wide stock-outs of condoms from 2008 to 2010, and that it was common for these stock-outs to last more than two months.
Ryan said the median availability of male condoms is only 9.65 condoms per man per year, with large variations from country to country. In 2008 Ethiopia, Cote d’Ivoire and Zambia received the fewest condoms per man from donors among the countries surveyed.
Uganda has had a history of such stock-outs, and Ryan’s presentation shows that in 2008 donors shipped only 7.9 condoms per man. A news report from last month indicates that in some northern districts in Uganda, health facilities have no condoms in stock for free distribution. HIV prevalence in the northern-central region of the country is about 8.2 percent, compared with the national average of 6.4 percent.
OGAC is working to understand the complex reasons behind the stock-outs, and in a forthcoming report the agency will address how the U.S. intends to respond. Ryan listed a number of factors leading to the shortages:
- Insufficient donor support for both condom provision and demand creation
- Ineffective funding mechanisms, such as ineffective basket funding
- Confusion over the U.S. government position on condoms
- Lack of prioritization of condoms by host governments
- Weak public sector supply chain systems
- Unfavorable regulatory policies – including import taxes and unnecessary post-shipment testing
Ryan also noted that similar issues led to insufficient supplies of female condoms. The Center for Health and Gender Equity reports that the U.S. has dramatically increased its distribution of female condoms in recent years, with shipments growing from 1.1 million in 2003 to 14.6 million in 2009. However, the Center notes that female condoms still represented just 3.2 percent of total U.S. condom shipments in 2009 and that “U.S. government investment in female condom procurement falls short.” In addition, the Center, which will be releasing a new report on access to female condoms, states that the U.S. is “not investing enough in programming to see the product really succeed.”
Ryan’s presentation listed a number of overall gaps in HIV prevention:
- Gap 1 – prevention efforts do not reach those who most need them
- Gap 2 – structural and human rights factors increase risk and vulnerability
- Gap 3 – fragmented interventions miss opportunities to interrupt transmission
- Gap 4 – prevention efforts lack resources and remain limited in scope
Condoms are an essential component in the fight against HIV/AIDS. Increased condom use is considered to have played a role in the decline in HIV incidence in Africa since 2001. According to the latest UNAIDS report, young people in a large number of African countries are reporting more condom use, as well as declines in sex before age 15 and a decline in multiple partners.
Yet, tracking U.S. spending on condoms is difficult. One study has shown a decline in U.S. support for condom provision between 2005 and 2008, however, it is unclear if the analysis considered all U.S. government funding sources, including PEPFAR. In fiscal year (FY) 2009, PEPFAR spent $272.5 million, including headquarters spending, in the budget category that includes condoms, “Other Prevention”, primarily through the U.S. Agency for International Development, up from $229 million in FY 2008, according to PEPFAR’s Operational Plans.
Insufficient donor support and a history of mixed signals on condoms have been top concerns of HIV/AIDS advocates. Concerns are also growing that the momentum for foreign aid cuts in the U.S. Congress will affect funding for HIV programs, including resources for purchase and distribution of condoms.
Notwithstanding objections to condom distribution by some conservatives, there is evidence that Americans from a wide variety of backgrounds, including Christian Evangelicals and Catholics, strongly support condoms for HIV prevention, and advocates hope that a strong message for prevention funding will lead to greater support in the Congress.