Expanding Safer Sex Options: Introducing the Female Condom into National Programmes

Abstract

Although the female condom has been introduced into over 90 countries since 1997, it has only been accepted in sexual and reproductive health programmes as a mainstream method in a few. This paper describes introductory strategies developed by Ministries of Health and non-governmental organisations in Brazil, Ghana, Zimbabwe and South Africa, supported by UNAIDS, and the manufacturers of the female condom, which have significantly expanded the number of female condoms being used. These projects have several key similarities: a focus on training for providers and peer educators, face-to-face communication with potential users to equip them with information and skills, an identified target audience, a consistent supply, a long assessment period to gauge actual use beyond the initial novelty phase, and a mix of public and private sector distribution. Female condom programmes require the sanction, leadership and funding of governments and donors. However, the non-governmental and private sectors have also played a major role in programme implementation. To ensure successful introduction of the female condom, it is crucial to involve a range of decision-makers, programme managers, service providers, community leaders and women's and youth groups. The rising cost of inaction and unprotected sex in the spread of HIV and AIDS force us to recognise the high cost of not providing female condoms alongside male condoms in family planning and AIDS prevention programmes.

Résumé

Le préservatif féminin a été introduit dans plus de 90 pays depuis 1997, mais rares sont ceux où il a été accepté comme méthode primaire dans les programmes de santé génésique. Cet article décrit les stratégies d'introduction préparées par les ministères de la santé et des ONG au Brésil, au Ghana, au Zimbabwe et en Afrique du Sud, avec le soutien de l'ONUSIDA, et les fabricants de préservatifs féminins, qui ont nettement accru l'utilisation de ces préservatifs. Les projets ont plusieurs similitudes: une priorité à la formation des prestataires et des éducateurs pairs, une communication personnelle avec les utilisatrices potentielles pour les informer et les former, un public cible identifié, un approvisionnement régulier, une longue période d'évaluation pour estimer l'utilisation réelle après la nouveauté du début, et une distribution partagée entre secteur privé et public. Ces projets exigent l'approbation, l'impulsion et le financement des gouvernements et des donateurs, mais les ONG et le secteur privé ont également joué un rôle majeur dans leur réalisation. Pour une introduction réussie, il faut associer différents décideurs, gestionnaires de programmes, prestataires de services, chefs communautaires et groupes de femmes et de jeunes. Le coût croissant de l'inaction et de relations sexuelles non protégées dans la transmission du VIH nous force à reconnaı̂tre qu'il serait onéreux de ne pas fournir des préservatifs féminins parallèlement aux préservatifs masculins dans les programmes de planification familiale et de prévention du SIDA.

Resumen

El condón femenino ha sido introducido en más de 90 paı́ses desde 1997, pero en la mayorı́a de ellos no ha sido aceptado como un método corriente en los programas de salud sexual y reproductiva. Este artı́culo describe las estrategias para la introducción del condón femenino desarrolladas por los Ministerios de Salud y organizaciones no gubernamentales en Brasil, Ghana, Zimbabwe y Sudáfrica, con el apoyo de UNAIDS y los fabricantes del condón femenino, las cuales han aumentado significativamente el número de condones femeninos en uso. Dichos proyectos comparten varios aspectos claves: un enfoque en la capacitación de los proveedores de servicios y los educadores de pares, comunicación directa con los usuarios potenciales, grupos destinatarios identificados, abastecimiento constante, un perı́odo largo para medir el uso más allá de la fase inicial, y distribución mixta entre los sectores públicos y privados. Estos programas requieren la sanción, liderazgo y financiamiento de gobiernos y donantes. Los sectores no-gubernamentales y privados también han jugado un papel importante en la implementación de los programas. Para asegurar la introducción exitosa del condón femenino, es preciso involucrar una gama de personas responsables de adoptar decisiones, administradores de programas, prestadores de servicios, dirigentes comunitarios, y grupos de mujeres y jóvenes. Las consecuencias de la inacción y el sexo no protegido exigen que reconozcamos el alto costo de no proveer el condón femenino junto con el condón masculino en los programas de planificación familiar y prevención del SIDA.

Key Words:

• female condom
• strategic introduction
• training of service providers
• social marketing
• HIV/AIDS
• Brazil
• Ghana
• Zimbabwe
• South Africa

The female condom is the only new method for preventing sexual transmission of HIV approved and introduced since the start of the epidemic, and there have been enormous obstacles to overcome in the course of introducing it to potential users. These include getting people to change their sexual behaviour, overcoming deeply rooted biases, especially among providers,¹ gender disparities, lack of knowledge of female genital anatomy, lack of communication between sexual partners and between providers and patients, and the stigma attached to all condoms, male or female. These issues are not unique to the female condom; in fact, very similar resistance was observed with the introduction of the tampon for sanitary protection in the 1930s.²

With correct and consistent use, the female condom is as effective as other barrier methods and has no known adverse effects or risks to health.³ A wide range of acceptability studies and field projects in many different countries and social and economic settings have shown that the female condom is acceptable to a number of women and men.^{4 5} The public health aim is to ensure that correct and consistent use is translated into additional protected sex acts.

Although the female condom has been introduced in over 90 developing countries since 1997, many of these programmes have been small pilot projects. They were viewed largely as procurement exercises and used available resources for purchasing female condoms and making them available in randomly chosen outlets, or alongside the male condom as an additional option. Many of these early programmes were also characterised by a lack of funding and strategic planning to identify a target audience, train providers or do outreach to potential users.⁶ Hence, although many countries rushed to try the method, many also became disillusioned when it became apparent that successful introduction would not be easy. Only a small number of countries successfully launched a successful female condom programme and maintained demand over time.

To assist the successful implementation of female condom programmes, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Female Health Company, makers of the female condom, carried out a joint project in 1999–2000 involving Ministries of Health and non-governmental organisations (NGOs) in 17 countries who had expressed interest and showed that there was a demand for the method. The project's aims were to:

• initiate female condom introduction;

• make high quality information available;

• respond quickly to requests for information and supplies of the female condom;

• support the development of introductory strategies;

• catalyse new ideas and expand good practices;

• advocate for effective integration of male and female condoms into national HIV/AIDS strategies and programmes.⁷

This paper presents case studies of four programmes that were successful in carrying out a strategic approach to female condom introduction, with success defined as a period of three years where female condom distribution is either maintained or increased.⁸ It draws upon the authors' experiences in over 20 countries in providing technical assistance in the design, implementation and monitoring of female condom programmes, and draws upon discussions with female condom programme managers, project reports and academic evaluations of female condom programmes. Its aim is to highlight the key ingredients that make up a successful programme and illustrate how these ingredients can be adapted to different developing country contexts. These are described in The Female Condom: A Guide for Planning and Programming.⁹

Strategic introduction

Brazil, Ghana, South Africa and Zimbabwe have had a quality female condom distribution programme in place for at least four years with the following key elements:

• an identified target audience to whom the messages and product are well delivered to ensure that users have a consistent supply;

• training for providers to ensure that possible provider biases do not negatively influence potential users;

• face-to-face communication to equip potential users with information and skills;

• a broad reproductive health focus that integrates family planning and HIV/AIDS prevention;

• a mix of public and private sector distribution; and

• a long assessment period to gauge performance of the distribution programme and to measure use of the female condom over time, not just during the novelty stage at programme inception.

Brazil

Planning for the introduction of the female condom in Brazil began with a large-scale acceptability study to inform the Ministry of Health of likely groups of potential users and strategies for reaching out to them. The Ministry of Health conducted a one-year pilot project, purposely designed to be much larger than previous acceptability studies, in six cities with 2,400 women users of public health services from varying cultural backgrounds, using 100,000 female condoms. Acceptability, which was defined as willingness to try, actually use and continue using the method, was calculated for an initial period of use (15 days after receiving female condoms and 90 days later). The response rate was high—93% of the women tried the method and 76% continued to use them, resulting in an overall 70% acceptability rate. This greatly exceeded the Ministry's expectations.¹⁰ Service providers in the public clinics were trained, and additional outreach workers in selected clinics were also trained. It was found that acceptability was highest among women and men reached through community-based outreach, carried out by trained community resource people. Hence, as the project has continued to expand, distribution has been increased through various community-based organisations. Record-keeping on distribution has been emphasised in order to monitor the success of the project.

At the same time, DKT do Brazil, a social marketing organisation, had initiated a successful female condom social marketing campaign in urban pharmacies, using the brand name “Reality”. The Ministry meantime was distributing female condoms free using the name “Preservative Feminino”. Both the government's programme and commercial sales of the product have been expanding. In 1998, the first year of social marketing, DKT sold 276,051 female condoms, while in 2000, they sold 543,865. Parallel distribution and promotion have widened the audience for the product and ensured that the female condom has not been stigmatised as a “free hand-out to sex workers”.

Based on the results of the study and the success of its initial strategy, the Ministry of Health developed an expanded, national programme which since the year 2000 now distributes over two million female condoms per year.¹¹ As the project expands, additional target audiences are being included: sex workers, HIV-positive women, women drug users and women at risk from violence. Women who are unlikely to be able to use the male condom due to situations of forced sex or high economic vulnerability have also been targeted. In this way the female condom is promoted to increase the overall number of women protected and not as a substitute for male condom use.¹² In 2002, four million female condoms were ordered for a still expanding programme.

Ghana

In Ghana, a partnership between governmental agencies, UN organisations and local grassroots organisations led to the development of a comprehensive female condom launch, targeted especially at young women. The involvement of local women's organisations ensured a strong community focus and the development of an extensive network of peer educators who gave a clear message from women to women that there was now a method of protection that they could initiate.

Prior to making the female condom available, the project partners trained more than 3,000 medical and non-medical service providers. In addition to training public health providers, the partnership also trained pharmacists in the private sector and local members of women's organisations as providers.¹³ The training curriculum included information about the female condom, dual protection from both unplanned pregnancy and infection, and negotiation and communication skills for using the female condom.

The government made the female condom available through the public health service, local women's organisations made it available to their members through the national affiliate of the Society for Women and AIDS in Africa (SWAA), and a local social marketing organisation ensured that the product was available in pharmacies and other shops, along with male condoms.

Before launching a nationwide campaign, the partners conducted a pilot study in the capital city, Accra. This involved the distribution of 18,000 female condoms and laid the groundwork for a full-scale national project delivering 1.5 million female condoms from mid-2000 through 2001.

“Our campaign has taken off so well that we have virtually no female condoms left now in the system. Demand is growing daily. Everywhere our network members go in the country, they are bombarded with requests for the female condom. To our surprise, men are also requesting the condom. Younger-aged women especially, who are our primary target group, are those making the most demand. They understand they are at risk and are taking action to protect themselves.” (A Lamptey. Personal communication, March 2002)

South Africa

The female condom introduction strategy in South Africa was developed over three years with regular consultation between the nine provinces and the National Department of Health. Initial introduction of the female condom was through family planning clinics and community-based programmes in order not to stigmatise the method as purely for disease prevention.¹⁴ In addition, based on initial experiences, outreach activities have been developed to include workplaces and other community settings, targeting women and men who practise high risk sexual behaviours and who do not attend traditional clinic-based services. These include sex workers, transport workers, university students and people living with HIV and AIDS.

Each province selected two pilot sites for distributing female condoms, and there was an extensive training of trainers, who in turn trained providers from the selected sites, provincial “master trainers” and provincial programme managers. The training programme, developed and implemented by the Reproductive Health Research Unit of the University of the Witwatersrand, covers dual protection, barrier methods generally, an update on male condoms, female condom introduction, data collection techniques and provision of emergency contraception pills, which were being introduced alongside the female condom as a back-up in cases of unwanted pregnancy. These now ongoing training activities are also expanding to include an additional focus on communication, counselling and negotiation skills.

This training and the overall project goal aims to integrate the female condom into the broader reproductive health programme, not just the HIV/AIDS programme. This reflects a larger strategy by the Department of Health to integrate HIV/AIDS and STDs within a framework that includes family planning and primary care, so as to optimise scarce resources and build long-term sustainability.

Both user and provider data has been instrumental in the design of the expanded South African National Female Condom Introduction Programme, which is currently expanding from 15 distribution sites to over 350 around the country.¹⁴ These sites include additional public sector clinics as well as workplaces, truck stops, brothels and universities. In addition to clinic-based distribution, the Society for Family Health, a non-profit social marketing organisation, is distributing the female condom through pharmacies and other outlets where male condoms are also sold. In addition, numerous employers have begun to purchase female condoms as part of workplace prevention and wellness programmes.

Quantitative and qualitative data from a sample of sites were collected in two phases, in 1998 and 2000, to examine the relationship between characteristics of women using female condoms and use patterns, to assess the influence of the service delivery system on female condom uptake. This study revealed that male condom use was not consistent and that the women choosing to use the female condom did so out of fear that male condoms might break and that some men might poke holes in male condoms, fail to put on the male condom or remove it prior to penetration. In addition, the ability to insert, remove and dispose of the female condom by themselves gave the women a greater sense of security. Overall, 88% of the 198 users who participated in in-depth interviews reported greater use of protection from both male and female condoms now that the female condom was available.¹⁴ In this setting, female condoms complemented rather than substituted for male condoms and women felt more empowered about protecting themselves.¹⁴

Zimbabwe

Perhaps the best example of advocacy for female-controlled prevention is in Zimbabwe, where a local community-based organisation played a central educational and advocacy role in introducing the female condom. An acceptability study by the Women and AIDS Support Network (WASN) showed high demand for a female condom.¹⁵ Armed with this information, WASN undertook discreet lobbying activities with the National AIDS Control Programme and other national bodies and initiated a press campaign, including a petition drive that garnered 30,000 signatures, to demand access to the female condom. In 1996, the drug regulatory agency approved the female condom for use in Zimbabwe. The result has been widespread distribution of the female condom, free through the public sector and commercially through social marketing to the general public.¹⁶

In 1997, Population Services International (PSI) Zimbabwe launched the most extensive female condom social marketing project carried out to date.¹⁶ During the initial research phase, it became clear that there was tremendous stigma attached to male condoms in Zimbabwe, as being specifically for STD/HIV prevention and with the connotation for many people of mistrust and promiscuity. In order to prevent the female condom from inheriting this stigma, PSI Zimbabwe decided to emphasise the contraceptive use of the female condom and launched the product with the brand name “Care Contraceptive Sheath”. Rather than target sex workers, it targeted married women who might be at risk because of their husbands' infidelity.

When women presented the female condom to their partners as a contraceptive method, the men were more accepting of the family planning message than one of disease prevention, which gave women an acceptable negotiating tool. This positioning should not be confused with the reason or motivation for using the method, which may not be the actual reason for using it, as many women may already be using more effective contraception. The positioning allows for both partners in the relationship to consider using the method without accusations or stigmatisation.

Initial training activities focused on pharmacists, who would be selling “Care”, and the project focused on mass media advertising. After initial high sales, there was a falling off from 20,000 units per month to 5,000. Follow-up research among users highlighted the need for better face-to-face communication with current and potential users to give them a place to discuss experiences and ask questions.¹⁷ PSI staff described the educational process as “akin to marketing the diaphragm, with more emphasis on interpersonal communication”, and a need to encourage repeat use, which required higher investment in face-to-face contact.¹⁸ After PSI added this component, working more closely with community-based organisations and institutions, sales increased by over 50% and current sales average in excess of 30,000 units per month.

At the same time as PSI Zimbabwe launched “Care”, the Ministry of Health launched a parallel, public sector female condom programme to reach more rural-based communities. In addition to reaching out to a different audience, the programme provides a constant feedback loop for the National AIDS Control Programme and clinic staff to adapt and expand distribution to new areas and users. This again highlights the importance of ongoing support and interaction with both users and providers. The Ministry's strong commitment to this process has also ensured that the female condom is a permanent part of the National AIDS Control Programme and budget, which ensures continued funding for and access to the device, a key element in a successful programme.

As in Brazil, the complimentary nature of public sector distribution and social marketing means that the two projects can provide the same product to different audiences, thereby making the product more widely available. Since 1997, both the social marketing and the public sector programmes in Zimbabwe have expanded and increased distribution significantly. However, there is still room for further expansion as community groups, especially women's cooperatives and groups, can reach audiences and communities that the public sector and social marketing cannot.³⁰

Female condoms are now providing additional protection from HIV and STDs in Zimbabwe. A study assessing the dynamics of use found that 16% of all women and 28% of married women using the female condom had never used male condoms prior to using the female condom. In addition, 20% of consistent female condom users who had previously used the male condom had not been consistent male condom users in the past, indicating that for them the female condom provided additional protection. Thus, female condom use had not replaced male condom use but brought about an incremental increase in protection, a finding which is consistent with other studies.^{19 20 21 22 23}

Integration of female condoms into existing services

Table 1 shows the increase in the number of female condoms distributed from 1998 to 2002 in the four project countries through public sector and social marketing projects.²⁴

As this was a new technology, there was an initial tendency to launch female condoms as a vertical programme, in isolation from other sexual and reproductive health or other community-orientated services. The post-war era development field was for a long time dominated by the belief that new technology in itself had rapid transformative potential without institutional change or social capacity-building. The emergence of the concept of primary health care was partly a reaction to the “over-technologising” of health and the need for horizontal rather than vertical health programmes.²⁵

Table 1 Number of female condoms distributed in four project countries, 1998–2002²⁴

Year	Number of Condoms
		Brazil	Ghana	South Africa	Zimbabwe
1998	610,400	18,000	95,000	302,000
1999	200,840	75,000	1,500,000	298,000
2000	2,602,600	420,000	2,079,000	373,000
2001	2,690,200	1,000,000	1,340,000	367,000
2002	2,539,000	n/a	1,212,000	1,575,000

The country case studies presented here have demonstrated a need to work within existing sexual and reproductive health structures, although an initial push to focus purely on the new technology is apparent in all. Each of the programmes worked with the Ministry of Health and activities were integrated into overall reproductive health service and product provision activities within Ministry of Health structures, whilst ensuring that parallel activities were undertaken by NGOs and community-based organisations, outside the official public health delivery system. Training was provided to personnel in the public sector as well as through community and social marketing structures, and distribution was within existing male condom distribution channels. Funding came from bi-lateral donors in close collaboration with local Ministry of Health support. In none of the countries has a separate “female condom organisation” been established to deliver exclusive programmes, as was the case with traditional vertical programming. However, resources in the form of people, programme support and training have been exclusively dedicated to a female condom “drive”. Particularly in the initial stages of advocacy, there is an important need to stress the relative advantages and programmatic differences that the female condom can add in terms of protection in a focused fashion.

Female condom programmes require the sanction, leadership and funding of governments and donors, but the NGO sector has also played a major role. Those countries which have successfully built up their female condom programmes have done so by consulting and involving multiple stakeholders from a broad range of programmes and projects, and integrating the female condom into existing, well-established activities. The case studies above highlight the training of a broad range of service providers, the inclusion of a broad constituency of stakeholders in government, social marketing, community-based health promotion, private sector actors such as pharmacists, and the use of multiple distribution channels. It is also crucial to involve a range of decision-makers, programme managers, service providers, community leaders and women's and youth groups.⁹

NGOs, community-based organisations and especially women's organisations (such as WASN in Zimbabwe and SWAA in Ghana) have been the lead advocates for the establishment of female condom programmes. They have mobilised government and donor support to introduce the female condom, placed the female condom within the larger context of overall community priorities, and promoted increased access to and acceptability of the female condom within the community in the context of broader cultural and political issues.

Cost and cost-effectiveness

The cost of female condoms is inextricably linked to the distribution of the method. While the over-the-counter cost of one female condom in the US and Europe is over US$2, efforts have been underway to make it less expensive for public sector distribution in the developing world. Since 1996, through collaboration between UNAIDS and the Female Health Company, the female condom has been available to public sector agencies in developing countries at a price of approximately US$0.57. Through this collaboration, the female condom has been supplied to Ministries of Health and NGOs in 80 countries in Africa, Asia and Latin America.

Even with a global public sector price, the female condom remains an expensive commodity compared to the male condom for three reasons, only one of which has the potential to change rapidly. First, the raw material is expensive; polyurethane is much more expensive than latex, which most male condoms are made of. Second, the manufacturing technology of female condoms involves high-tech welding and moulding of polyurethane which is more expensive and complex than the latex dipping methods used in male condom production. Third, the overall volume of female condoms sold is much lower, fewer than 12 million per year globally (2002), compared with over one billion male condoms per year in Africa alone. While the female condom in its current polyurethane form cannot become as inexpensive as a male latex condom, the price can be reduced substantially as global volume increases.

It is an inevitable “catch 22” that donors and Ministries of Health are reluctant to purchase large quantities of female condoms because of the high unit price and that the manufacturer cannot reduce the price unless large quantities are ordered. UNAIDS and the Female Health Company are therefore working aggressively to increase global volume in an effort to accelerate a price reduction.⁸

In addition, the comparative economics of male and female condoms and cost-effectiveness issues are much more complex than unit cost alone. While it is far cheaper to buy male condoms, there is increasing evidence that additional protection is provided by the female condom, which is cost-effective in spite of the unit cost. For example, a recent study suggests that well-designed female condom programmes can not only be highly cost-effective but can also save public sector health funds, especially in programmes that target groups that practise high-risk behaviours, such as sex workers and others with multiple partners, and where it adds protection within an existing programme.¹⁹ This is an argument for public sector subsidy of female condoms, to save public health costs associated with STD and HIV diagnosis and treatment.²⁶ This argument certainly helped motivate the Ministries of Health in Brazil, Ghana, South Africa and Zimbabwe as well as the donor agencies that supported the efforts in these countries.

Technical issues

Cost and cost-effectiveness measurements have also influenced important technical issues. While the female condom was approved for single use only, the practice of re-use has been documented in several countries over the past few years. Re-use is due to many factors, especially limited availability, high unit cost relative to the male condom, perceived strength of the female condom and, perhaps most of all, the limited options available to women—often a choice must be made between re-using a female condom or having no protection at all.^{27 28 29}

WHO, UNAIDS and USAID, among others, have conducted numerous studies to investigate the safety and feasibility of re-use after disinfection, washing, drying, storage and re-lubrication, and WHO has convened two technical consultations to review data from these studies. The studies clearly indicate that disinfecting, washing and drying a female condom up to seven times does not harm the structural integrity of the device.^{30 31 32}

WHO recommends use of a new female condom for every act of intercourse. Recognising the urgent need for risk-reduction strategies for women who cannot or do not access new condoms, WHO has developed a draft protocol for the safe handling and preparation of used female condoms for re-use. The protocol, together with guidelines on programmatic issues, is on the WHO website,³³ and also in the November 2002 issue of Reproductive Health Matters.³⁴ Any updates will likely be posted on the WHO website.

Cultural and social contexts, and personal circumstances, will determine when female condoms are re-used; the balance of risks and benefits will vary with the individual user. For providers, the decision whether or not to support re-use of female condoms must ultimately be taken locally.³³ Additional guidance may be useful so that programmes can consider the most appropriate risk reduction strategies in these contexts.

Education and training

A major component of female condom programmes must be to address the educational needs of users, promotional materials and training for service providers. Health providers and, perhaps more importantly, peer educators and outreach workers must develop an expertise in answering queries about sexuality, female anatomy and specific issues about the female condom in small groups and one-to-one situations.

Service providers can be uncomfortable about recommending products they are not familiar with. Training for service providers needs to include the role that the female condom can play in dual protection, how counselling services can effectively be provided and a review of programme implementation issues likely to arise.^{1 35}

These successful interventions encourage a “practice makes perfect” attitude, and do not over-complicate female condom use. They incorporate information about anatomy, sexuality, communication and negotiation skills; they respect women and provide opportunities for them to develop a sense of self-efficacy and self-confidence in using female condoms and self-worth about protecting themselves and their partners.^{1 36 37} The benefits of these initiatives go far beyond potential female condom use. In fact, they raise many of the same issues that will need to be addressed with the introduction of microbicides in future.³⁸

Women have typically been the target audience for the promotion of female condoms, yet in many countries, men still maintain the dominant role in sexual decision-making, including decisions related to contraception and prevention of STI/HIV. Targeting men in promotion and education has proven effective in improving overall acceptability of the method.^{9 39} More time and attention need to be committed to motivating men to accept and support female condom use, particularly men who rarely practise safer sex.

Conclusion

Global advocacy remains necessary to ensure that policymakers and programme managers at all levels understand the role the female condom can play, the challenges of introducing it (present with any new method) and the potential benefits for public health, both in economic terms and in terms of women's health. UNAIDS has taken the lead in advocating for additional prevention methods under the control of women and has been at the forefront of supporting expanded female condom initiatives.⁵ Translating this global support into local action is of the highest priority.

The problems of resource allocation, the importance of female-controlled prevention methods and the right of women and men to have access to and choice from among a range of methods are not unique to the female condom. Barrier methods for protecting sexual and reproductive health have a history of meeting resistance at many levels. When the introduction of a new technology is not successful, explanations for programme failure may fall too heavily on the product itself, rather than on the failures of introduction strategies. However, the rising cost of inaction and unprotected sex in the spread of HIV and AIDS forces us to recognise the greater costs of not providing more female condoms alongside male condoms in family planning and AIDS prevention programmes.