The female condom was developed in the 1980s. It is a contraceptive device used by women that protects against both pregnancy and sexually-transmitted diseases (STDs) including HIV infection. Two studies have investigated the contraceptive effectiveness of the female condom, and it was found to be as effective as other barrier methods. It has been shown to be effective against STD and HIV transmission in vitro but there is only limited evidence of its efficacy in vivo. No serious local side effects or allergies have been reported and the female condom can be used with any type of lubricant, spermicidal cream or foam. The female condom is the only device other than the male condom that has been shown to prevent HIV transmission. The female condom has been marketed in 13 countries since the summer of 1996. Most of these countries are industrialized and the selling price in these countries is too high for developing countries. Sub-Saharan Africa has very high prevalence rates for HIV infection, at least 30% of the general population in Eastern and Central regions. The epidemic is also spreading fast in some parts of the Western region. In Ivory Coast for example, 12 to 15% of pregnant women are infected. African women are subordinate to men in many aspects of their lives, politically, educationally, socially and sexually. This sexual inequality makes them highly vulnerable to STDs, including HIV, and unwanted pregnancies. This paper reviews 10 of the 15 studies carried out in sub-Saharan African countries between 1990 and 1996 and compiled by the World Health Organization. Recruitment methods, education of subjects, methodology and assessment of acceptability differed between studies. Despite these limitations, most studies concluded that the women who participated in the trials generally found the female condom acceptable. Acceptability was established quicker among prostitutes than among other women and men found the female condom less acceptable than did women. However, the sample size is too small to draw any firm conclusions. Commercial sex workers in the studies reviewed were very interested in this new method because it gave them an additional method of safer protection during sex. However, they were occasionally faced with difficult negotiations with some clients, refusal to use the female condom and sexual violence. Reuse of the device was reported in four studies, but the term reuse is seldom defined. In cases where it was defined, the frequency of reuse, with washing of the device, accounted for no more than 1% of the total number of uses. The acceptability of the female condom among women other than prostitutes faces two obstacles, the reaction of the woman's regular partner and attitudes to the device itself (appearance, difficulties or uneasiness concerning its use). However, some women liked it because it provided dual protection against pregnancy and STDs and sexual pleasure. The moderate level of acceptability to male partners may be overestimated because women whose partners disliked the device would be more likely to discontinue its use. The studies of acceptability reviewed here show that use of the female condom in Africa is realistic and that it provides women with more independent protection. Initial negative perceptions of the device are often replaced with a more positive reaction after several uses. The experience gained with use reduces the technical problems. We need to overcome the stereotypes, simplifications and strong opinions that threaten to damage the acceptance of this new method and efforts to encourage women to adopt it. However, we still require further clinical data on the effectiveness of the female condom at preventing pregnancy and HIV transmission. Availability of the female condom is improving in Africa. Pilot marketing studies were launched in 1996 in Guinea, Zambia, South Africa, followed by Uganda and Tanzania. There are local initiatives in Ivory Coast and Zimbabwe. (ABSTRACT TRUNC
PIP: This work discusses the female condom and the context of women's lives in sub-Saharan Africa, analyzes results of studies on acceptability conducted in Africa, and assesses the prospects for future use of the method in Africa. Studies have been conducted throughout the world on the efficacy, tolerance, and acceptability of the female condom. The two studies of contraceptive effectiveness, carried out in England, the US, and Latin America, showed it to be about as effective as other barrier methods. Both studies had high dropout rates. The female condom has been demonstrated to be effective in vitro against transmission of HIV and sexually transmitted diseases, but evidence of efficacy in vivo remains limited. The high prevalence of HIV infection in eastern and central Africa and its rapid spread in parts of western Africa, and the growing desire of African women to space or limit births, indicate a need for protection that could be met by the female condom. The subordinate position of African women at all levels limits their ability to negotiate on sexual topics, including contraception. 10 of the 15 studies of acceptability of the female condom, carried out in 9 sub-Saharan African countries between 1990 and 1996 and compiled by the World Health Organization, were reviewed. The studies were limited by small sample size, selective recruiting, lack of consistency in methods and analysis, and a tendency to ignore dropout rates and motives. Despite the limitations, the studies found female condoms to be acceptable to certain groups of women, especially prostitutes. Acceptability was established more rapidly among prostitutes, although large proportions reported the method to be unacceptable to some of their clients. Results of acceptability studies were more variable among non-prostitutes. Acceptability among men has been insufficiently documented. Stereotypes and oversimplifications must not be allowed to hamper promotion of the female condom. It is recommended that further study of the contraceptive and disease prevention efficacy of the female condom be conducted and that availability and accessibility of the method be increased for African women.