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WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific
PROMOTING CONDOMS IN CLINICS FOR SEXUALLY TRANSMITTED INFECTIONS A practical guide for programme planners and managers
2001 1
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Contents Abbreviations and Acronyms Acknowledgements Foreword 1. About this Guide 2. STI Prevention and Condoms 3. Creating a Favourable Environment for Condom Promotion 4. Training STI Service Providers 5. Counselling STI Clients on Condom Use 6. Developing Tools for Condom Promotion 7. Ensuring and Managing Condom Supplies 8. Monitoring Co ndom Use in STI Services 9. Additional Resources 24 27 iii iv 1 3 4 8
13 16 20 22
ANNEXES 1. An exercise for service providers to determine 29 their comfort levels in discussing condom use 2. Exercises in condom desensitization for health 31 care workers
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ABBREVIATIONS AND ACRONYMS
AIDS CSM HIV MCH/FP MOH STI WHO WPRO
acquired immunodeficiency syndrome condom social marketing human immunodeficiency virus maternal and child health/family planning Ministry of Health sexually transmitted infections World Health Organization WHO Western Pacific Regional Office
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ACKNOWLEDGEMENTS The Western Pacific Regional Office of the World Health Organization would like to thank Mayada Youssef Fox for her contribution to this manual.
WHO Library Cataloguing in Publication Data Promoting Condoms in clinics for Sexually transmitted infections
1. Sexually transmitted infections - prevention and control. 2. Condoms. I. World Health Organization. Regional Office for the Western Pacific.
ISBN 92 9061 1553 The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland or to the Regional Office for the Western Pacific, Manila, Philippines which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 2001 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
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FOREWORD
The
Western Pacific region of WHO is facing an increasingly serious epidemic of sexually transmitted infections (STI). We estimate that there are over 35 million cases of curable STI every year in the Region. Additionally, an estimated total of one million people are infected with HIV in the Region by the end of 2000. The health consequences of STI can be serious. The complications and long-term effects of untreated STI can be very serious, especially in women. Newborn babies can also suffer from STI acquired from infected mothers, with potentially serious consequences. STI can also facilitate the sexual transmission of HIV. The presence of an untreated STI can increase the likelihood of HIV transmission by up to ten times. Condoms are our only means of preventing STI (including HIV) transmission in risky sexual situations. Condom programme activities are therefore essential components of public health approaches to STI prevention and control. These activities include: • • • educating people about the need for condom use; ensuring condom availability; and providing support for condom use and condom programmes.
STI clinics have a special role to play in promoting condom use among patients engaging in risky sexual activities. With active and effective promotion on condom use, STI clinics can contribute to a significant reduction in STI and HIV transmission. I strongly urge all STI health workers to take responsibility for actively promoting condom use on a regular basis by STI patients.
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The continuing high level of STI, and increasing HIV infection in some parts of the Region highlights the need for action by Member States. WHO continues to work to support STI, including HIV, prevention and control activities by Member States and we hope that this document will support public health professionals to design more effective programmes.
Dr. Shigeru Omi Regional Director World Health Organization Office for the Western Pacific
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1.
ABOUT THIS GUIDE
The promotion of condom use among patients with sexually transmitted infections (STI) is important in the prevention and control of STI, including HIV. This guide aims to help STI programme planners and managers to improve condom promotion among STI patients. It reviews the major areas in condom promotion for STI services, including: creating a favourable environment; training service providers; counselling clients on condom use; managing condom supplies; and monitoring condom use. Some additional resources and sample exercises are also outlined. Further information and technical support in promoting condoms for STI prevention may be obtained from the World Health Organization, Regional Office for the Western Pacific. . BOX 1: Key messages for condom promotion among STI patients 1. STI patients should use condoms: u if they have sex while they or their partners are under treatment, and u in the future, in order to prevent further STI infections. 2. All patients attending STI clinics should: u be counselled about the importance of condoms in preventing STI; u be shown how to use a condom correctly; u leave the clinic with some condoms, in case they have sexual intercourse while they or their partners are under STI treatment; and u be told where they can purchase or be given regular supplies of condoms. 3. Condom promotion should be undertaken in all clinics that offer STI services, including: u u u u specialized STI clinics; maternal and child health and family planning (MCH/FP) services; outpatient clinics; and primary health care services. 3
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2. STI PREVENTION AND CONDOMS Importance of STI prevention and control There are three important reasons to prevent and control STI: • • • the large number of STI; the serious health consequences of STI; and the increased likelihood of HIV transmission among patients with STI.
STI, including HIV, are major health problems around the world. In many countries, STI and their complications are among the top five reasons that adults seek health care. STI have serious health consequences. The complications and long-term effects of untreated STI can be very serious, especially in women. Newborn babies can also suffer from STI acquired from infected mothers, with potentially serious consequences. STI also facilitate the sexual transmission of HIV. The presence of an untreated STI can increase the likelihood of HIV transmission by up to ten times. Also, because of their
BOX 2: STI prevention and control components u u u u u u u Promoting safer sexual behaviour Promoting health care-seeking behaviour Integrating STI control into primary and other health care services Providing specific services for populations at increased risk Comprehensive case management Prevention and care of congenital syphilis and neonatal conjunctivitis Early detection of asymptomatic and symptomatic infections
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“higher-risk” sexual behaviour, individuals who have acquired STI are more at risk of HIV infection. Therefore, an important part of HIV prevention is the rapid and effective treatment of STI.
The key role of condoms in preventing STI Along with reducing overall levels of infection in at-risk populations, preventing STI (including HIV) relies on promoting safer sexual behaviour in any sexual intercourse where STI infection is a possibility. A major part of safer sexual behaviour is using condoms in risky sexual relationship. Condoms are important both to prevent STI infection (primary prevention), and to prevent the transmission of an STI to other sexual partners (secondary prevention). Condom programme activities are therefore essential components of public health approaches to STI prevention and control. These activities include: • • • educating people about the need for condom use (demand creation); ensuring condom availability (supply activities); and providing support for condom use and condom programmes.
The three components of the condom programming process - demand, supply and support - are summarized in box 3.
BOX 3: Condom programming process Demand Research Promotion Targeted Distribution Supply Logistics Forecasting Procurement Distribution systems Quality management 5 Support Policy Management Training
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This guide focuses on condom promotion among STI clients, which is only one part of this larger condom programming process. To successfully promote condoms in STI services requires support from many of the other elements of the condom programming process. More information on these other components can be obtained from some of the publications indicated in section 9, “Additional resources”.
The key role of STI programme planners and managers in condom promotion in STI services STI programme planners and managers have an important role to play in promoting condom use programmes, especially in STI clinics. These roles include: • advocacy and support for the development of policies and regulations: for example, convincing policy leaders about the importance of condoms in STI prevention and control; ensuring that policies and regulations support the promotion of condoms in the STI services; mobilizing necessary resources: for example, ensuring that financial resource budgets for STI services include condom supply; and that good quality condoms are made available and accessible to STI services; developing training: for example, making sure that health workers providing STI treatment have the knowledge and skills to promote the use of condoms and to counsel clients and their partners accordingly; supporting education activities: for example, supporting the development of educational materials to promote condom use among patients and of media activities to advertise the use of condoms for STI prevention; targeting educational programmes for those most at-risk of STI; monitoring and evaluation of condom activities.
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3.
CREATING A FAVOURABLE ENVIRONMENT FOR CONDOM PROMOTION
Increasing support for condom promotion Influential leaders, service providers or policy makers may have negative views about condoms. Things STI planners/managers can do to increase support include the following: • Provide policy-makers with the results of research showing STI prevalence, and illustrate the costeffectiveness of promoting condoms. Indicate that the chances of STI being transmitted when condoms are properly used are almost nil. Emphasize that condoms are electronically tested. It is better to be almost perfectly safe when having sexual intercourse using a condom, than to risk being entirely unsafe without a condom. Provide journalists with data proving the reliability of condoms, and refer to studies which prove that HIV, STI, and sperm cannot pass through a latex (rubber) condom. Point out that, after a condom is on and in use, people forget that it is there. They get used to using condoms: the disadvantage of any reduced sensation is small when compared to the satisfaction of not having to worry about disease transmission, in particular HIV. Point out that condom uses reduces the chance of becoming infertile through an STI or of developing cervical cancer. Hold seminars (or include briefings in training programmes) for health workers to make them aware of the STI problem.
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Convincing that condom promotion is effective It has been established that condom promotion results in increased and repeated use of condoms as well as a decrease in STI rates. It is essential to provide successful condom promotion experiences. These are helpful in discussions with policy makers, influential leaders and health staff. Examples of successful experiences in Asia include Thailand and Cambodia where the 100% Condom Use Programme in entertainment establishments has resulted in a dramatic increase in condom use and a drop in STI rates. (In one province of Thailand, condom use rose from 30% to 90% and STI rates dropped from 13% to less than 0.5%).
Revising laws and regulations It is important to identify existing laws and legislation which may restrict condom promotion and distribution activities in STI services and to try to revise them with the help of relevant people and sectors. Such regulations may include: • • laws that impose high taxes on imported condoms; policies that restrict the open promotion and distribution of condoms due to prevalent sociocultural and religious norms; policies that restrict the smooth ordering, distribution and management of condom supplies to STI services.
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STI planners/managers should also identify regulations that will support STI services in condom promotion by, for example: • including condom promotion and condom counselling in the tasks of STI service providers; including condom supplies programme budgets; in STI control
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introducing routine prescription of condoms to STI clients – as is the case with drugs; drafting policies supporting free distribution of condoms.
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Preparing STI guidelines, plans and budgets Condom promotion and distribution activities must be included : • in national MoH technical guidelines and protocols for management of STI patients, where condom use should be clearly stated as part of case management of patients with STI (This should include when and how condoms are prescribed; whether they are to be donated or sold; who is to supply the condoms and how; and who, at the clinic level, is responsible for educating and counselling about condoms, and for providing instructional materials to complement the prescription of condoms); as part of guidelines for preventive services to be provided in STI services; in regional and district STI control plans and budgets, as part of logistics and supplies management; in pre- and post-service training activities for STI service providers (Sufficient time needs to be allocated for sessions on condom promotion and counselling); in formulating the post descriptions of STI service providers; and in media programmes and other events that address HIV and STI prevention strategies.
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Selecting the institution(s) or agency(ies) responsible for condom activities A focal institution or agency, whether in the public or private sector, has to be designated as responsible for planning, implementation and monitoring of condom promotion activities in STI services. This can be the same group that handles MOH condom programme activities, such as STI, family planning, or AIDS programmes, or condom social marketing (CSM) projects. Responsibility should be specified at various managerial levels (central, regional, district, community).
Defining the tasks of STI service providers Condom promotion is greatly facilitated in STI services if it is officially included in the job descriptions and duties of service providers. This ensures that condoms are routinely ‘prescribed’ to clients. Specifically, tasks may include: • checking with clients whether they have used or are using condoms and what brands they are familiar with; checking the problems clients have encountered in acquiring and using condoms; demonstrating (preferably with a model penis) how condoms should be used and disposed of; providing information on condom effectiveness and use; advising clients on how to facilitate the use of condoms with their sexual partners; and providing information on the availability of condoms, the brands available, sizes, prices and types.
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It also helps if - on relevant occasions such as training sessions, field visits,or official meetings - this issue is raised and reinforced.
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Promoting condom use among the general public Prevention campaigns and social marketing activities rarely target STI clients and STI services. STI planners can take the following initiatives in this regard: • Public promotion of condoms can start in the STI clinic by maintaining and displaying useful and attractive information. Examples include posters and charts on the walls, leaflets and brochures to hand out to clients, videotapes to show (if equipment is available), as well as free condoms to give away. STI clients can also be targeted in the community, through HIV/STI prevention activities, such as outreach programmes, visits by local community health workers, and home based-activities, such as those run by family planning or AIDS care programmes.
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Condom social marketing (CSM) programmes have succeeded in increasing the use of condoms in many countries. STI planners need to negotiate officially with CSM managers to plan and implement appropriate activities to cover STI services and target individuals at risk of STI, such as providing a regular supply of condom advertisements in entertainment establishments.
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4. TRAINING STI SERVICE PROVIDERS STI service providers must have the appropriate knowledge, attitudes and skills to carry out condom promotion activities. In general, most health professionals are comfortable and skilled in dealing with the medical issues. However, they often find it hard to address related sexual behaviour. Training should target all health workers dealing with STI: doctors, nurses and other health professionals. In order to enhance the knowledge and skills of STI service providers in condom promotion, the following steps should be considered: • integrating condom promotion into the basic training and refresher training of health professionals; producing practical guidelines and self-learning materials; including condom promotion in the STI care protocols that are usually issued by the Ministry of Health or national health institutions.
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The objectives of the training should cover three main areas: knowledge, attitudes and skills. Knowledge: The technical knowledge of service providers related to condoms should be improved through such means as: • becoming familiar with the characteristics of condoms and the various brand types available; understanding the effectiveness of condom use in preventing the transmission of sexually transmitted infections, including HIV; learning how condoms should be used and disposed of; learning about MOH policies with regard to condom promotion in general;
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learning about specific policies regarding condom availability and distribution in STI services, such as free donations, prescription by service providers; learning how condom supplies and logistics are managed; and learning about the common obstacles to condom promotion.
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Attitudes: The attitudes of service providers with regard to condom effectiveness and use should be improved through: • acquiring an understanding of social norms and attitudes in general, enabling service providers to respond to clients’ concerns about condoms (see section 5); and acquiring an understanding of how age, gender, educational level, social class, beliefs, values, income level, sexual behaviours and preferences may affect practices and attitudes towards condoms.
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Service providers should be helped in clarifying their own values with the aim of overcoming personal prejudices about condom use. Discussing intimate subjects, such as sex and condoms, can make people uncomfortable, even those working in STI prevention. Skills: STI service providers should be equipped with the appropriate skills to enable them to: • • communicate effectively with STI clients and counsel them on condom use issues ; manage supplies of condoms at clinics, including checking their validity and identifying stock needs (see section 7); and monitor the utilization of condoms by clients and keep track of problems and constraints (see section 8).
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BOX 4: Common obstacles to condom promotion u There may be a lack of clear policy for support from official authorities.
u Condoms may not be seen as reliable and the quality of condoms available locally may be perceived as poor. u Condoms may be believed to reduce the pleasure of sex. u There may be a fear that condoms can get lost in a woman’s womb. u People may reject condoms because they don’t see any benefit in using them. u There may be opposition on the part of religious and/or sociopolitical authorities to condom promotion. u There may be a fear that condom promotion encourages sex. u There may be opposition from clients or bar owners to condom promotion with commercial sex workers. u There may be opposition from health professionals, including nurses, to the use of condoms. u There may be rejection of posters and pamphlets that explicitly mention condoms and sex.
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5.
COUNSELLING STI CLIENTS ON CONDOM USE
STI service providers need to carry out the following basic tasks when counselling and educating their clients about condoms: Explain about condoms, what they are made of, how they function and how effective they are. Following are some basic facts about condoms: • A good condom is a latex condom that is lubricated and has been stored out of direct sunlight in an unopened package. When the condom is touched it will feel soft and pliable – not brittle or sticky. Condoms generally remain in good condition for at least three years after the manufacturing date on the outside of the package. Condoms are made on individual moulds shaped like a penis. Each condom on each mould passes through electronic beams that detect even very tiny holes or other defects, such as the latex being too thick or too thin. When a defective condom passes through the beam, an alarm is sounded and the poor quality condom automatically falls off the assembly line. Condoms are also tested for strength by being inflated with air and for permeability by being filled with water. Laboratory tests also prove that viruses cannot pass through the condom. Unlike some means of birth control, using a condom has no physical side effects. It cannot harm the user (unless the person is allergic to latex). Some people say using a condom reduces the physical sensation of sex. However, others accept that any disadvantage is small when compared to the pleasure gained from not needing to worry about disease transmission.
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Condoms are made in different sizes. However, manufacturers distribute only certain sizes in certain areas of the world. The length of condoms may vary from 150mm to 180 mm and the width from 44mm to 56 mm. Condoms will never feel like naked skin. Simply accepting this and exploring the sensations of latex can increase the pleasure of condoms. If condoms are seen as part of the pleasurable process of lovemaking instead of a hygiene device, many problems are eliminated. Condoms can be put on by sexual partners and become an exciting part of sex, instead of an interruption. Additional water-soluble lubricant can enhance sensations when using condoms. The lubrication that is usually on condoms helps, but is not usually enough. Putting a small amount of lubricant in the reservoir tip before putting a condom on can heighten pleasure. This helps keep air out of the tip and greatly increases sensation when the lubricant seeps around the end of the penis. It takes a little practice to apply the right amount. Consistent use of condoms is the only contraceptive method that prevents both pregnancy and sexual transmission of diseases, including HIV. Some vaginal contraceptive products containing a spermicide, such as nonoxynol-9, have been shown in the laboratory to be lethal to HIV and some STI pathogens. However, it is not yet possible to recommend their use for STI prevention, except as an adjunct to proper and consistent condom use. Female condoms have been developed and have undergone extensive testing. They are available commercially in some countries. Laboratory studies have shown that an unbroken polyurethane (plastic) female condom does not allow the passage of sperm or viruses. The female condom is, at present, less comfortable to use than the male condom and is much more expensive. However, it may be useful for vulnerable women when their male partner is drunk or refuses to wear a condom.
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Demonstrate how a condom is used, including how it is accessed from its package and how it is disposed of. Inform clients on how to get condoms, whether they are donated free or have to be purchased, where they can be obtained and how much they will cost. Provide condoms to clients before they leave the clinic, especially those who appear to be shy or insecure about the whole situation. Provide materials such as brochures and booklets that will give clients additional information (see section 6). Help clients to overcome resistance to condom use, including negotiating with their sexual partners (see box 5).
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In addition to the above tasks, it is very important that service providers are familiar with the profile of their clients, including their personal traits, their occupations, their social situations, what they know, what they believe and how they behave. This will affect the way they counsel their clients about condoms. For example: • In many cultures, women are less likely than men to come to STI services for prevention or treatment. For this reason, service providers should emphasize to their male clients the importance of protecting their female sexual partners (whether they are wives, commercial sex workers or girl friends) and, even more, of convincing them to pay a visit to the clinic if a sexually transmitted infection is suspected. Young people often avoid visiting STI services for fear of being recognized and judged by their community. STI services should facilitate the use of services by training service providers in how to communicate better with young people, and by having “youth-friendly” days.
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5. Common points of resistance to condom use and possible responses from PromotingBox Condoms in STI Services WHO/WPRO STI service providers
STI Clients Can’t afford condoms
Service Providers Condoms are often available free of charge or cost no more than other items that are purchased regularly, such as toiletries, tobacco or alcoholic drinks. (STI service providers should inform clients where to get free condoms or, if not possible, which brand(s) are good value.) STI services and pharmacies are used to selling or providing condoms and don’t usually have any prejudice about it. They are more concerned that people with STI get their condoms. Think of condoms like medication and do not be embarrassed to ask for them. If your income permits, help your partner relax by offering a variety of condoms from which he or she can choose. Develop the habit of using a condom every time you have sexual intercourse until it becomes second nature. Keep condoms handy and available.
Too embarrassed to handle or obtain condoms
Forgets to use them
Implies I don’t love or trust my partner, I know my partner does not have an STI
Unless you/your partner have been properly tested for STI, including HIV, and are absolutely sure that neither of you has been sexually involved with other people, it is necessary to keep using condoms. Some STI, including HIV, do not show symptoms for long periods; anyone can have an infection and pass it to another person without knowing. It is important in any relationship, whether in or outside marriage, that you are sincere with your partner about the diseases you have, especially STI. You must be concerned about your partner’s health. Convince your partner to use condoms. Bring your partner to the clinic if you need help with your partner’s counselling. Take the condom out of its wrapper and make sure you talk to your partner about it before starting; incorporate putting it on as part of foreplay. Check the type of condom you are using, check its expiry date or look for signs of wear on condom packaging, like worn corners or discoloration. Also keep condoms in cool places and avoid exposure to the sun. Practise condom use on your own by opening the package and putting the condom on a banana. Hold the condom at the base of the penis.
My partner would guess that I have an STI, or my spouse would suspect something
Distracts from sex
Condoms break
Condoms slip off Condoms stay inside Hold on to the condom at the base of the penis and withdraw gently. Use a water-based lubricant or saliva. Never use an oil-based lubricant, such as petroleum jelly, butter, baby oil, vegetable or animal fat. Use lubricants or thin condoms to help increase sensation. Condoms may reduce sensation when they are first put on and during insertion, but once they warm to body temperature, most people can’t tell they have them on.
Vagina gets dry
Condoms reduce sensation
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6.
DEVELOPING TOOLS CONDOM PROMOTION
FOR
Although promoting condoms in STI services will be done mostly through routine interpersonal communication and counselling, it can also be carried out by other means, such as: • • • • • distribution of print materials; distribution of popular promotional items such as key-rings, pins, shopping bags, etc. advertising information on clinic walls; showing informational videotapes; organizing mini-campaigns in the community in collaboration with local organizations and volunteer groups (This could include theatre, health fairs, seminars, etc.); or conducting visits to homes and schools where appropriate.
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A selection of good tools definitely help service providers in their task of promoting condoms in the clinic. Basic tools required include: • • brochures or leaflets on how to use condoms (see sample brochure presented in box 6); penis models to demonstrate condom use with STI clients during counselling, and with service providers during training sessions; posters or charts to illustrate basic information on condom use and STI prevention; and if possible, and equipment is available, videotapes depicting condom use and basic information on STI prevention.
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It is most likely that the above tools are already available in the country from sources such as AIDS prevention projects, family planning services or social marketing agencies. In this case, arrangements should be made to supply STI services with sufficient copies for promotion and/or distribution. If this is not the case, STI managers need to work with appropriate collaborators to design and produce their own materials for the specific purpose of condom promotion. The following points should be kept in mind when providing or producing promotional materials : • Print materials should state clearly the relation between STI prevention and condoms. If materials only mention HIV and AIDS, or family planning, STI clients may not make the link for their own situation. Such information should be available on the leaflets that usually accompany condom packets. The print materials which are selected or produced should contain simple language, as close as possible to the local slang or spoken language. Language should be replaced or backed up by illustrations whenever appropriate and possible. Information on partner notification and caring about sexual partners should be prominent in the materials.
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BOX 6: Sample brochure on condom use 1 Condom
2
Open the package carefully so the condom does not tear. Do not unroll the condom before putting it on. 3 4
If not circumcised, pull the foreskin back. Squeeze the tip of the condom and put it on the end of the hard penis.
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Continue squeezing the tip while unrolling the condom until it covers all of the penis. 6
Always put the condom on before entering partner.
After ejaculation (coming), hold the rim of the condom and pull the penis out before it gets soft. Remember: • Do not use grease, oils, lotions, or petroleum jelly (vaseline) to make condoms slippery. These make condoms break. Only use a lubricant that does not have oil in it. Use a condom each time you have sex. Only use a condom once. Store condoms in a cool, dry place. Do not use condoms that may be old
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Slide the condom off without spilling the liquid (semen) inside.
• Throw away or bury the condom. • • •
Do not use a condom if: the package is broken; the condom is brittle; the colour is uneven or changed; or it is unusually sticky.
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7.
ENSURING AND CONDOM SUPPLIES
MANAGING
A plan should be available for regular procurement, sale and distribution of condoms in identified STI services throughout the country, especially in rural and remote areas. It is important that STI managers understand some of the basic issues involved. This will enable them to negotiate and collaborate with specialists as well as make appropriate financial and managerial decisions vis-à-vis the official health authorities. Key issues to remember include: • Knowing who is/will be handling condom activities. STI managers should designate a focal organization to oversee the planning, implementation and monitoring of condom promotion activities. This can be the same organization as is handling condom programming, or a separate one that specializes in promotion activities. It can be from either the public or the private sector. Specialized nongovernmental organizations and social marketing agencies are usually very well equipped to handle logistics management of condoms. Most countries already have ongoing CSM projects, often addressing HIV prevention and family planning issues. Usually STI clients and services are inadequately targeted by these projects. In areas where there is no CSM project, STI managers and service providers should link up with family planning and HIV prevention programmes to ensure effective procurement and distribution of condoms for STI services. Requesting a plan for logistics. The focal organization should submit a plan describing in detail how the procurement and distribution of condoms will take place. This should also include the basic specifications of condoms to be distributed (making sure they match the criteria set by WHO) as well as the timing of events, including dates when condoms will be available in the STI services. Estimating the quantity of condoms needed. As part of the plan, proper forecasting should be conducted to ensure an adequate continuous supply of condoms for STI
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services. STI managers should make sure that this supply is not mixed up with other supplies, such as .for family planning or HIV prevention. Whether or not forecasting has been done or is to be done, STI managers should demand to see a breakdown of the condom figures. In addition to quantities, an assessment could also include a study on the condom brand preferences of STI clients.
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8.
MONITORING CONDOM USE IN STI SERVICES
Condom promotion can be considered successful if it leads to increased awareness and continued use of condoms among STI clients. In countries or areas where condom use among STI clients is poor or needs boosting, it is important for STI managers and service providers to monitor closely what progress is being made. The purpose is to improve and correct what is being done in terms of counselling, training, and condom promotion and distribution, as well as to make relevant managerial decisions. STI managers should incorporate an evaluation component in their condom promotion plans and activities. This should specify the following: • Who is responsible for carrying out monitoring tasks. At the central level (national/regional/district), the focal institution designated to coordinate condom programming activities will be responsible for managing monitoring activities as they relate to condom promotion. At the clinic level, STI service providers should be trained to keep records on condom distribution and use. What is to be monitored and at what level (national, district, community). It is useful to identify, right from the start, the type of indicators for monitoring condom promotion activities. There are many indicators of interest to condom programming managers. However, given the limitation of resources, including funds, and the limited time that health staff usually have available, STI managers need to be selective in what they wish to evaluate in terms of progress and impact.
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With regard to progress indicators, It is important to study the following, especially at the start of programme activities: • Focal institutions and individuals: whether these have been designated by official authorities to handle management of condom promotion activities, especially at the district and community/clinic levels.
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Condom promotion guidelines: whether the appropriate health authorities or institutions have issued special instructions on condom promotion to be incorporated in STI control protocols. Guidelines should be available at all programme levels (central/national, regional, district, clinic). Task description: whether STI service providers have received instruction to incorporate condom counselling into their jobs at STI services. Training of STI service providers: what is the proportion of staff who have received training in condom promotion, whether through pre- or postservice programmes, as well as those who have received learning manuals on the subject. Condom promotion materials: the type and number of materials and tools produced for use by STI services, and the number of materials distributed by services to STI clients. Distribution of condoms: what are the quantities of condoms distributed to STI services, and how many condoms have been donated or sold to STI clients.
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On the other hand, there are impact indicators, which are needed to determine the effect of condom promotion on the STI situation, including clients’ practices. These include, for example: •Reported condom use: what do STI clients report on their use of condoms, including whether this use is consistent and continuous. •Incidence of sexually transmitted infections among STI clients, especially those targeted by STI services. Data on progress indicators is easier to collect than that on impact indicators. The latter requires skills in research techniques. Depending on the situation and resources, STI managers may wish to consider the following :
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When data on condom sales/distribution and use is regularly collected by CSM agencies, STI managers should make sure that information, relevant to STI clients and services, is included. In collaboration with social marketing experts, STI managers should develop rapid assessment protocols for use by STI service providers (who need to be trained for this purpose). A number of STI services could be selected as focal points (in key areas in each region/district) to run quick surveys at regular intervals, such as every 4 to 6 months, to investigate condom-use practices among STI clients. STI service providers should be encouraged to conduct focus group discussions with STI clients in order to identify problems and constraints relating to condom use. It would be helpful to provide STI services with appropriate guidelines on how to conduct these groups and how to interpret the data gathered.
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9. ADDITIONAL RESOURCES For detailed information on specific areas of condom promotion, STI managers and their collaborators should refer to other key materials such as: Condom promotion for AIDS prevention: a guide for policy-makers, managers and communicators. Geneva, World Health Organization, 1995. This document is designed for policy-makers and managers of AIDS programmes. It provides information and guidance on how to establish a framework to conduct condom promotion in the context of HIV prevention. 100% Condom Use Programme in Entertainment Manila, World Health Organization Establishments. Regional Office for the Western Pacific, 2000. A guide to advocating for condom promotion in the sex work industry and to establishing pilot projects. Website: www.wpro.who.int The Male Latex Condom. Geneva, World Health Organization/ Joint United Nations Programme on AIDS, 1998. This is a compendium of materials, designed to address programmatic and quality assurance issues relevant to the production, procurement, promotion, distribution and use of male latex condoms. It includes three parts: Specifications and Guidelines for Condom Procurement; 10 Condom Programming Fact Sheets; and a Monograph on The Latex Condom. CONDOMS CD-ROM: The multimedia resource on condoms. Baltimore, MD, Johns Hopkins University, Center for Communication Programs and the United Nations Population Fund, 1999.
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This is a searchable, multimedia database allowing direct access to a comprehensive, international collection of information on condoms. It also includes thousands of Popline citations with descriptive abstracts, and 1200 pages of texts on condoms, including the Johns Hopkins’ Population Reports on condoms. Contact address: Popline Digital Services Center for Communication
Programs Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.
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Annex 1
An exercise for service providers to determine their comfort levels in discussing STI and condom use This exercise is based on the premise that people being asked to promote the use of condoms will have individual opinions and varying degrees of comfort in dealing with the subject, especially in face-to-face communication or counselling settings. The exercise helps educators realize that teaching people about condoms is extremely important and to do so effectively requires acknowledging personal attitudes and values about condoms and understanding how these could affect condom promotion work. Step One: Take a few minutes to read the statements listed below. After each one, think about how comfortable or uncomfortable it makes you feel. Rate your level of comfort with each of the ten activities below with a range of (1) extremely comfortable to (5) extremely uncomfortable. Your responses will not be shared with anyone else unless you so choose. 1. Displaying a condom promotion poster in your office.
2. Giving people you meet brochures on safer sex, including graphic pictures on condom use. 3. Reviewing the importance of condom use with someone of the opposite sex seeking advice. 4. Demonstrating for a group the correct way to put on a condom by using your fingers or another object. 5. 6. Being asked for your personal opinion about condoms being given to teenagers. Discussing the importance of condoms with family and friends.
7. Being asked if you personally use condoms and answering about your own experience. 8. Being told by a woman that her husband might harm her if she insisted on his using condoms. 9. 10. Hearing that someone refuses to ever use a condom because of religious beliefs. Going into a pharmacy and buying condoms.
Step Two: Based on this exercise, list the barriers that you may personally face in meeting
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with people to discuss condom use. Mark the barriers with which you most identify at this time. Step Three: Take a few moments to think about how to start removing those barriers most personal to you.
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Annex 2
Exercises in condom desensitization for health care workers 1. Pass condoms out to participants and ask them to open the packages, examine them, stretch them and even blow them up into balloons. Demonstrate how to put them on, using a banana. Have the participants take turns to demonstrate how to put the condom on a banana. 2. Have the participants assess their personal comfort when dealing with condoms
3. Identify at least four participants, with equal numbers of men and women. Conduct a brief discussion on arguments for and against using condoms. Record the points made on a blackboard or flip chart. Select a man and a woman to role-play a situation in front of the others. Create a sample situation, or use or adapt this one: Rami, a local bus driver recently met Maya through a mutual friend. They were immediately attracted to each other and their relationship has progressed quickly. Rami has asked Maya to spend the night with him. She has accepted and is thinking about how to approach the issue of condom use. Rami has used condoms in the past but doesn’t like them much. Maya has had a bad experience with an ex-boyfriend who had an STI. After the role-playing, invite participants to suggest strategies that they have found helpful in convincing their sexual partners to use condoms. Write these down. Invite a general discussion about strategies for negotiating condom use and have the group discuss the effectiveness of the arguments presented. Ask another man and woman to repeat the roleplaying situation. Review the important points brought up in the role-plays and the discussions following them and then ask the participants for feedback on the points you have raised. 4. Divide participants into small groups of three or four participants each. Instruct the members of the groups to brainstorm about the advantages and disadvantages of condom use. Ask the groups to select a spokesperson to record and report the group’s ideas (20 minutes). Ask the participants to return to the large group and share the ideas discussed in their small group. Record the ideas on sheets of paper or a board. Review these points, add others that you may think of, and invite discussion by the participants. 5. Give all the participants condoms and ask them to blow them up into balloons. Use this to make the point that condoms are strong and can expand to many times their size without bursting. You can also make the point that the condom will not let through small molecules such as oxygen so it will stop much larger particles such as the viruses that cause STI or HIV.
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6. Using a model of a penis (or a banana), demonstrate how to remove a condom from the package properly and put it on an erect penis. Ask the participants, in groups of four, to practise putting condoms on to models. Ask the groups to identify any problems in following the procedures outlined and appoint a spokesperson to report on their discussion. Ask the groups to report back and write down the difficulties they identified on a large sheet of paper. Use this to discuss the problem of tearing condoms with fingers, improper storage, use of petroleum lubricants and difficulties in disposal. Invite the participants to suggest how these problems might be solved. Emphasize the importance of instructing clients about use whenever condoms are distributed.
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WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific STI, HIV and AIDS Focus United Nations Avenue (P.O. Box 2932) 1000 Manila, Philippines Fax: (632) 521-1036, 526-0279, 526-0362 Tel: (632) 528-8001 E-mail: HSI@wpro.who.int Web site: www.wpro.who.int
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