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A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya.

Thomsen SC, Ombidi W, Toroitich-Ruto C, Wong EL, Tucker HO, Homan R, Kingola N, Luchters S. Sex Transm Infect 2006 Oct;82(5):397-402.

Abstract

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OBJECTIVE: To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education programme for sex workers in Mombasa, Kenya. DESIGN: A 12 month, prospective study of 210 female sex workers. METHODS: We interviewed participants about their sexual behaviour every 2 months for a total of seven times and introduced female condoms after the third interview. We also collected cost data and calculated the cost and cost effectiveness of adding the female condom component to the existing programme. RESULTS: Introduction of the female condom in an HIV/AIDS prevention project targeting sex workers led to small, but significant, increases in consistent condom use with all sexual partners. However, there was a high degree of substitution of the female condom for male condoms. The cost per additional consistent condom user at a programme level is estimated to be 2160 dollars (1169 pounds sterling, 1711 euros) (95% CI: 1338 to 11 179). CONCLUSIONS: The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen here, governments should limit promotion of the female condom in populations that are already successfully using the male condom. More research is needed to identify effective methods of encouraging sex workers to practise safer sex with their boyfriends.

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Commentary by UCSF Institute for Global Health

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Objective

To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education program for sex workers in Mombasa, Kenya.

Study Design

A twelve-month pre- and post-intervention evaluation.

Setting

Study participants were female sex workers who lived and/or worked in the Kisauni division of Mombasa district in Kenya, a major seaport and trucking center on the Trans-East African highway. Kisauni is a popular tourist spot, with many bars, guesthouses, and discos.

Participants

Participants were recruited through an existing HIV-prevention peer education project run by the International Centre for Reproductive Health in Mombasa. Peer educators provided a list of 329 peer sex workers, which a study team used to randomly select a sample for screening. A total of 210 female sex workers were then eligible based on the inclusion/exclusion criteria, and were interviewed on their sexual behavior every two months for one year. The average age of the study participants was 29 years old, and the average participant used at least one method of contraception.

Intervention

The intervention consisted of female condom education through peer education and information, education and counseling (IEC) materials, and provision of female condoms starting at month four of the study.

Primary Outcome

The primary outcome was consistent condom use with all sexual partners in the seven days prior to each interview. Consistent condom use could be male condom use, female condom use, or both. Secondary outcomes were the number and proportion of protected sexual acts with different partner types. There was also a separate cost-analysis component used to determine what additional resources would be required to support provision of female condoms through an existing peer promotion program, and the cost-effectiveness of the intervention.

Results

Of the 210 female sex workers in the study, 149 provided data on condom use consistently. Among this group, the proportion of participants reporting consistent condom use with all partners increased from 59.7% to 67.1% (p=0.04) following the introduction of female condoms. Forty-two percent of the previously inconsistent condom users became consistent users at the final visit, but 16% of the previously consistent condom users reported inconsistent condom use at their last visit. The mean number of casual clients, regular clients, and unprotected coital acts also decreased during the study. Use of male condoms declined from 84% per sex act to 57% following the introduction of the female condom. The total cost of the intervention was $54,139, or $258 per participant. If scaled up to reach the 2,382 sex workers in the Kisauni division, the annual cost for the female condom promotion would be $380,081, or $160 per person.

Conclusions

The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen in this study, governments should limit promotion of the female condom in populations that are already successfully using the male condom.

Quality Rating

There is no widely accepted quality-scoring tool for pre/post-intervention evaluations like this study. The design, which had no control group, makes it difficult to separate the effects of the intervention from secular trends. However, given the rarity of female condoms in Mombasa, increased use of female condoms outside the study was not very likely. In addition, the study sample was small and taken from a list of sex workers generated by peer educators, and may not be representative of other sex workers who do not participate in similar peer education groups. With the exception of the cost-analysis portion, measures were self-reported and subject to bias. Other biases noted by the authors were the numerous discussion sessions held with the study participants during the intervention, which likely were a co-intervention and may have positively influenced some of their responses.

In Context

The main result from this study, the introduction of the female condom into a male condom program, resulting in a small increase in the proportion of sex workers reporting 100% condom use with all partners, replicates what has been found in other sex workers (1,2) and high-risk populations.(3,4,5) However, increases may not always be accompanied by decreases in sexually transmitted diseases and may be due to over-reporting.

Programmatic Implications

The high cost of the female condom alone would represent a substantial investment by a ministry of health, and it seems unlikely that a similar free female condom distribution intervention could take place without donor assistance. However, in situations where male condoms are not consistently used, introduction of the female condom to sex workers can provide them with a safe strategy to prevent HIV and other STIs.

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References

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2. Ray S, van De Wijgert J, Mason P, Ndowa F, Maposhere C. Constraints faced by sex workers in use of female and male condoms for safer sex in urban Zimbabwe . J Urban Health. 2001 Dec;78(4):581-92.
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3. Musaba E, Morrison CS, Sunkutu MR, Wong EL. Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia . Sex Transm Dis. 1998 May;25(5):260-4.
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4. Artz L, Macaluso M, Brill I, Kelaghan J, Austin H, Fleenor M, Robey L, Hook EW. Effectiveness of an intervention promoting the female condom to patients at sexually transmitted disease clinics . Am J Public Health. 2000 Feb;90(2):237-44.
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5. Feldblum PJ, Kuyoh MA, Bwayo JJ, Omari M, Wong EL, Tweedy KG, Welsh MJ. Female condom introduction and sexually transmitted infection prevalence results of a community intervention trial in Kenya . AIDS. 2001 May 25;15(8):1037-44.
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