Sunday, 23 September 2012

The Condom Situation Assessment in 11 Asian and Western Pacific Countries




WORLD HEALTH ORGANIZATION

Regional Office for South-East Asia
Regional Office for the Western Pacific




STI/HIV
 




The Condom Situation Assessment in
11 Asian and Western Pacific Countries[1]

June  2001












STI/HIV



The Condom Situation Assessment in 11 Asian and Western Pacific Countries



 



Introduction                                              2

I: Overview                                                          3

II: Country Reports                                           
Bangladesh                                                          9
Cambodia                                                                        11
China                                                                    14
India                                                                     18
Indonesia                                                              22
Myanmar                                                             25
Nepal                                                                    27
The Philippines                                                    29
Papua New Guinea                                             32
Thailand                                                               35
Viet Nam                                                              38





Introduction


This report was designed to provide a brief overview of condom promotion strategies and activities in 11 Asian and Western Pacific countries. 

The objective of Section I: Overview is to highlight issues and problems related to condom promotion that appear common among the countries in this overview.  Some suggestions for remedial actions are suggested.  Section II: Country Reports is a synopsis of those major issues, strategies, activities and constraints in the individual countries surveyed.

WHO wish to thank especially all those national professionals who provided information used in this report, as well as collaborating colleagues in the South East Asian Regional Office, the Joint United Nations Programme on AIDS (UNAIDS), the United Nations Population Fund (UNFPA), and the various Condom Social Marketing Programme officials working in the affected countries. Special thanks go to Dr. Robert Fischer who coordinated the collection of data and preparation of this report.

Section I:  Overview

 


The individual country assessments in this report provide evidence of a great breadth of strategies, activities accomplishments and constraints that different countries are facing in promoting condom use, each within the context of its unique historical, social, political and economic framework. Clearly a "one size fits all" condom promotion strategy may not be suitable in the face of such national and regional diversity.  It is possible, however, to see many issues and problems related to condom promotion that appear to be common to most countries. Suggestions are also evident for remedial actions that should be considered.

Condom programme evaluation

Perhaps the most revealing and important problem revealed in this situation assessment is the lack of uniform information about condom promotion activities in the different countries. Despite many years of condom promotion programmes throughout the world, there does not appear to be widespread consensus on how these programmes should be monitored and evaluated. 

It appears to be difficult for most countries to generate comprehensive figures on the annual number of condoms distributed. Condom social marketing programmes rely heavily on overall changes in sales figures. Some indication of overall condom availability can also be obtained from private sector commercial sales figures. However, where "black-" or "grey-market" importation and distribution of condoms is an important element in a country, these legal sales figures may not be telling the whole story. NGO condom importation and distribution programmes may also be important but not reflected in overall sales statistics.

As noted in the country reviews in Section II of this report, there are many KAP and DHS surveys in the international literature that give some suggestion of how effectively and extensively condoms are being used in selected groups (e.g., reported consistent use of condoms in commercial sex, or contraceptive preference or continuation rates). While these studies are important, they are often conducted  in  samples  of  convenience.  It  is  difficult to determine how

representative one study may be of more general trends in the country, or how representative of changes over time when compared to another study.
 

Actions to be considered:  In the final analysis, it
will be incumbent on institutions or individuals in charge of national condom promotion programme to identify the indicators and evaluation strategies of their country programme. Internationally, however, there is a need for agreement on some common parameters on which these national programmes are progressing.

Efficacy v effectiveness

In virtually all countries discussed in this report, it is evident that national public health professionals understand the great utility which condoms hold for national programmes, for both fertility regulation and disease control. There also appears to be strong professional understanding that, although the theoretical "efficacy" of condoms is very high, the "user effectiveness" (how the average person actually uses and/or misuses condoms) presents the greatest public health challenges. There are two main issues confronting the professional community: (1) how to ensure that highly "effective" quality condoms are accessible to the population and (2) how to ensure that people understand their utility and are motivated to use them "effectively."

Some countries do not have sufficient quantities of high-quality condoms to meet current and future demands.  Other countries are more concerned in promoting condom use, especially among individuals with high-risk sexual behaviours. Ultimately, both issues must be addressed adequately in a successful condom promotion programme.


Actions to be considered: Condom promotion programmes should have a well balanced approach both to (1) creating demand for high quality "effective" condoms and (2) generating understanding and motivation on how to use these products consistently and "effectively".  It will behove managers of currently successful programmes to remain alert to the adequacy of future condom supplies as their programmes expand.



Short-term v long-term risk reduction interventions


 
Public health planners have to make a decision between risk-reduction interventions which are "short-" or "intermediate-term" in time frame (e.g. promoting the routine and consistent use of condoms in high-risk sexual relations) and "long-term" (e.g. working to reduce or eliminate exposure to high-risk multi-partner sexual relations). 

In this report, it is evident that the "short-term intervention" of promoting condoms has been controversial in some places because it would seem to promote high-risk sexual relationships. These short-term interventions (“making high-risk or socially marginal kinds of sexual relations more safe”) might seem to some to be contrary to the objectives of the longer-term conservative social goals of the traditional culture.

Some policy-makers argue that public health agencies should concentrate their efforts on these short-term interventions with immediate health effects, and that longer-term, behavioural interventions or efforts to preserve the traditional social norms would be better left to other agencies such as NGOs or religious institutions.

Actions to be considered:  There is no simple solution to this debate or dilemma. A condom promotion strategy must be pursued in harmony with other social goals. Condom labelling regulations in at least one country require that condoms all carry a message stressing the importance of sexual abstinence and mutual fidelity. A similar strategy may prove useful in other countries where there is much concern about the interplay of short- and long-term risk reduction interventions


Family planning v disease prevention 

Condoms have two predominant functions; fertility regulation "contraceptives", and disease prevention "prophylactics."  Education campaigns on these two functions can sometimes be confounding to the public. Often, where there have been vigorous public health education campaigns on condom use for disease prophylaxis, married couples have expressed reluctance to use condoms for contraception because of the "dirty" or "sex-for-pleasure" connotation associated with the technology. This association can make it "embarrassing," for example, for someone to purchase condoms.

Actions to be considered: Public health policy and programme planners must be sensitive to the issue and to the problem that some condom promotion can present for the contraceptive users of condoms.

Core groups and condoms

It is well understood that "core groups" (individuals with a high-risk of acquiring and transmitting infection) constitute an important element in the epidemiology of STIs (including HIV). Indeed, the identification of core groups for special condom promotion programmes appears to be an important element in all 11 countries. Commercial male and female sex workers are universally recognized as an important core group for special attention. In other countries, there has been recognition of other groups that require attention and are somewhat dependent upon prevailing cultural norms in the country or region. Included in this list of other common core groups are: truck drivers, taxi drivers, military and police personnel, miners, factory workers, injecting drug users, urban youth, and men who have sex with men (MSM).

Actions to be considered:  it is incumbent on national health policy planners and condom promotion programme managers to have a keen sense of relevant core groups within their country or community and to identify practical and effective programme strategies to impact on these different populations.

 

"Protect yourself" and "Protect others"

The message to "protect yourself" through the use of condoms when in high-risk sexual encounters has been an important part of many national condom programmes. Much less common in programmes has been encouragement to "protect others." Commercial sex workers often report higher levels of condom use with their paying customers than with their regular non-commercial sexual partners or boyfriends. Reports from other areas (e.g. among transvestites and MSM) have also revealed important differences in condom use depending
upon whether the respondent has been engaged as a "penetrative" or "receptive" partner in an encounter. The ongoing risk for married women who may be exposed to STI/HIV through their husband's extramarital sexual encounters is also widely acknowledged.

Actions to be considered: Although it is sometimes a difficult message for a public health programme, the idea of "protecting yourself and protecting others" must be a part of any comprehensive condom promotion programme.   

Why people say they don't use condoms

Why people don't use condoms in the face of apparent need and knowledge about their effectiveness is one of the more problematic issues in national condom promotion programmes. Why they don’t use them and why they may say they don’t use them may be two completely different issues. There is, however, an interesting similarity across countries on "what people say" about their constraints in using condoms. 

Widely reported are popular complaints that condoms emit an unpleasant odour, inhibit sexual gratification, irritate the partner's sexual organs, and interfere with intercourse.  Female commercial sex workers are often under much pressure not to require use of condoms from male customers most concerned with sensually pleasure-oriented sex.

Outside of use for mutually agreed contraception, married couples or regular sexual partners often state that they are reluctant to use condoms because of what it might suggest regarding confidence in their partner's fidelity, or, as noted above, because of the association between condoms and dirty sex.

The expense of condoms is now rarely reported as a burdening constraint in condom use, especially in countries with condom social marketing programmes promoting low-cost brands. On the other hand, reports are common relating to the "embarrassment", or social stigma many people feel in purchasing something so intimately related to sexual activity.


Actions to be considered:  Condom promotion programmes should  address these kind of expressed constraintsbyh adjusting condom technology (colouring, "flavouring", lubrication and/or texturing condoms), promoting their use in ways which may make them a more appealingly enjoyable part of sexual relations, or working with distributors of condoms on techniques to make clients feel more comfortable requesting or purchasing supplies.



Section II  - Country Reports



BANGLADESH[2]

Bangladesh has been recognized as an HIV low-prevalence country but also one at high-risk due both to its proximity to high prevalence countries and endemic high-risk behaviours. [3]  It is also a country in which it has been noted that there is an extreme paucity of epidemiological and behaviour research on HIV/AIDS, STDs, and risk factors.[4] Despite longstanding condom social marketing, recent studies still point to disturbingly low condom-related knowledge and practices.

Condom use

The use of condoms in high-risk commercial sex has been the subject of several studies in Bangladesh. A 1995-96 study of 102 prostitutes in the Tanbazar brothel of Narayangonj found that only 9.8% had heard the term "AIDS" and none of the respondents used condoms regularly.[5] In another later project to evaluate the effectiveness of peer outreach education in a brothel of 600 women, investigators found a 12x increase in condom use over a 12-month period (from 3% to 36%).[6] Another similar peer education project at the Faridpur brothels between May and December 1997 demonstrated an increase in regular condom use from 3% to 13%.[7]


The national AIDS programme has recognized the existence of a widely occurring form of high-risk male-to-male sexual practices in the country.[8] Prior to opposite sex activities, young males (as early as 8-9; though more commonly between
13-15) are initiated into male-to-male sexual activities by older youths. Sex with boys is reportedly seen as a safe substitute for sex with dangerous female sex workers and it is also observed that "most men" claim they do not use condoms when engaged in this activity.  The generally secret nature of this high-risk activity, and the age of the involved youths have been seen as major challenge for public health programmes.
 

Final-year students in higher secondary colleges in the Manikganj District of Bangladesh were studied with regard to their knowledge of HIV/AIDS. Among a number of findings of concern was the apparent discovery that 90% of the students did not believe that condoms had a role in AIDS prevention. [9]

Condom social marketing

The Social Marketing Company has been in operation in Bangladesh since 1974. Its Condom Social Marketing Component has expanded its programme over the years to include the promotion of three different condom products. Raja, its lowest priced condom (US$0.007 a piece) was first sold in 1975 and had logged cumulative sales of 1.8 billion as of 1998, with annual sales of 112 million in that same year. Sale of the little more expensive Panther condoms (US$0.025 a piece) began in 1983. By 1998, it had cumulative sales of over 175 million condoms and annual sales of 27 million.  Promotion and sale of Sensation condoms (US$0.05 a piece) was launched in 1992/1997. Cumulative sales by 1998 had reached 18 million and it was seeing annual sales of 3 million. This mature social marketing project benefits from the support of the United States Agency for International Development (USAID), the Dpartment for International Development of the United Kingdom (DfID) and the European Union (EU); and it collaborates widely with bilateral agencies, the UN and local NGOs and industry. Plans are underway to begin franchising pharmacies under the “Blue Star" programme to promote a number of contraceptive technologies and condoms.[10]


CAMBODIA[11]

Confronting one of the most serious HIV epidemics in Asia, fueled by a vigorous "direct" and "indirect" commercial sex industry, Cambodian health authorities have long seen the benefits of condom promotion for disease prevention. The social marketing of condoms has been well developed and knowledge of condom utility is generally widespread among the public. Recent national effort to implement a "100% Condom Use" programme, integrated with vigorous STI care activities targeting commercial sex establishments, is seeing an increase in condom use among commercial sex.

Condom needs and availability

There have been a number of estimates of national condom needs for Cambodia. In 1997, a study by AIDSCAP/Family Health International concluded that about 1.85 million condoms per month would be required if condoms were used in 90% of commercial sex encounters. The United Nations Task Force on Condom Supply and Distribution in Cambodia estimated monthly needs at 6.6 million or over 80 million per annum. Another study estimated the overall potential commercial market for condoms in Cambodia at 25 million units per year.

Condoms are distributed through a wide variety of national health programmes, including family planning clinics and STI clinics, although supplies are sometimes limited. The latest DHS (Preliminary Report 2000) finds that 28% women using condoms for contraception got them through the public sector (primarily provincial hospitals), 5% through the private medical sector, 38% from pharmacies and 19% from other retail outlets. A number of NGO projects in Cambodia also distribute condoms.

In 1998, an important "100% Condom Use" pilot project was initiated in Sihanoukville, a resort and port town situated in southwestern Cambodia. This project, adapted from experience in neighboring Thailand and linked closely

with an EU-supported STI prevention and care initiative in Sihanoukville, has sought to ensure condoms are used in all commercial sex acts. A vigorous public, multisectoral IEC component has supported the project goals. The project has witnessed very encouraging results. Behavioral studies have shown that the rate of condom use increased from 42% in 1997 to 53.4% in 1998 and to 78.1% in l999 in Sihanoukville; and 64% of female sex workers also reported "always" condom use with their boyfriends or regular non-commercial sex partners.[12] The National Policy on 100% Condom Use was drafted in a National Policy Workshop in 1999 and was formally promulgated as national policy in September 2000.
 

The commercial sale of condoms, supported by a vigorous condom social marketing programme, has been a very important and successful channel for promoting knowledge about condoms and supplying condoms  to the population.

Condom social marketing

Population Services International (PSI) has overseen a condom social marketing programme in Cambodia since 1994[13] with the wide support of Australian Agency for International Development (AusAID), DFID, the Dutch Government, the Embassy of Finland and USAID. PSI has developed and markets its own brand "Number One" (at a price equivalent to about $US 0.18-0.20 a piece) through a vigorous programme to promote condom use among sexually active young adults, commercial sex workers and their clients, and members of the military and police. Sales of condoms in Cambodia increased dramatically from 99 000 in 1994, 5 032 000 in 1995, 9 516 000 in 1996,
10 500 000 in 1997 and 11 537 000 in 1998.[14]  PSI attributes this unanticipated

initial growth  of sales, at least in part, to its innovative IEC programme and sales training efforts. [15] [16]
 

Condom use

An important study at Calmette Hospital in Phnom Penh among 307 HIV-positive patients, revealed a high association between HIV infection and multi-partner heterosexual relations (70% of men)[17]: 57% of men reported that they never used condoms; the remaining 43% claimed they used them only "sometimes".

Condom use in commercial sex was not a norm in the past. However, because of the initiation of several national and local programmes promoting their use, there is widespread public knowledge about the utility of condoms in disease prevention. The DHS (Preliminary Report 2000) showed that 82% of urban and 67% of rural women had such knowledge.  An earlier 1998 survey in Phnom Penh, Kandal and Kampong Cham revealed that 92% of all respondents and virtually 100% of interviewees in brothels, hotels and pharmacies knew about the socially marketed "Number One" brand condom. However, this knowledge has not yet translated into high use rates in commercial sex. Two other studies of commercial sex behaviours in Cambodia also reported high knowledge about condoms among CSWs, but low usage.[18] [19]

Condoms are not generally seen in Cambodia as things that are used among married couples. It is estimated that only 0.9% of couples use condoms for fertility regulation.


CHINA[20]
 

Health leaders in China are acutely aware of the utility of condoms in both family planning and disease prevention programmes. However, efforts to promote condom use have been necessarily cautious and constrained by prevailing traditional and conservative sexual mores in the country.

Data has shown that 600 000 people in China have AIDS or are infected with HIV. Recognizing this growing public health threat, the State Council recently issued the "China Action Plan to Contain, Prevention and Control of HIV/AIDS, 2001-2005" – a five-year plan of action to combat
the spread of HIV/AIDS in the country. Interventions that have proven effective and feasible in local circumstances are being promoted by the Central Government through this plan. A core intervention is condom promotion in all public establishments.

Condom needs and availability

There are seven major condom manufacturers nationwide, reportedly producing between 1.3 to 1.5 billion condoms annually. The level of imported condoms is not well documented, although it is apparently quite significant (with at least one report of some 25 different imported condoms available in one market place, the majority of very poor quality). Current national condom productive capacity and imports, however, are far below what might be needed if condoms were effectively promoted and used for high-risk sexual encounters. In an exercise using the official 1998 statistics on the number of commercial sex workers in China (4 million, with 3-4 clients per week each), health authorities have concluded that the annual need for condoms could exceed 800 billion.   

Formally, condoms are under the official control of the State Family Planning Commission (SFPC), which is not part of the Ministry of Health. In spite of the fact that condoms are made available to married couples through family planning facilities at the subsidized price of 0.20 Yuan a piece, their use remains limited, related in part to problems in public understanding of their efficacy and
allegations of poor quality (breakage, smell, lack of sensitivity). The SFPC established new condom standards to take effect in early 2000.

The UNFPA is executing three projects in China focusing on condom promotion and distribution, including a project to promote condoms through the railway system, another targeting commercial sex workers active in the city of Luizhou in Southern China, and a project working on a national condom strategy for China.

Condoms are not routinely made available or promoted in other health institutions, including STI clinics.

Condoms have traditionally been sold only at pharmacies for contraception (1-2 Yuan for domestically produced condoms and as much as 14 Yuan a piece for imported products).

Condom social marketing

In an effort to expand contraceptive availability, the SFPC has installed condom vending machines in 15 cities and some more rural localities. Target populations for this effort include especially college students and migrant workers. As this initiative is focused exclusively on expanding contraception availability, there has reportedly been little coordination with the Ministry of Health on its potential to serve broader health needs in the area of disease prevention.

DKT International launched a condom social marketing programme in China in 1996, whereby domestically produced condoms (and smaller quantities of imported condoms) are made available through broader commercial outlets (including some supermarkets). This effort is situated in 10 provinces and cities, with a target population of 400 million people. Although DKT recognizes both the family planning and HIV/AIDS prevention focus of this programme, it has been constrained by national law and overall characterizes its efforts as "cautious" with "timid generic messages" about contraception. Despite these limitations, DKT claims that 52 million condoms have been sold through the programme since its inception and that its current annual sales are 25 million.[21] 

Condom use
 

Despite the fact that condoms have been exclusively distributed in China in relation to contraception, it does not appear a popular method of fertility regulation among couples. One report estimates regular condom use for contraception at less than 5%. In a study of sexual behaviours among rural residents of China, it was concluded that just over 10% of residents reported condom use for conception, although only about 10% of those used them for every sexual act.[22]

Despite a lack of reported studies about condom use in commercial sex in China, there appears to be some consensus that sex work has been increasing since 1989 and that there are 3 to 4 million sex workers working on the mainland.[23] One small and older study among commercial sex workers and their clients in Hong Kong suggests that condoms may be used regularly less than 30% of the time.[24] [25]  A recent survey among Hong Kong residents returning from visits to mainland China revealed that 32.5% had had sexual intercourse with a commercial sex worker in mainland China in the past six months, 11.2% during their latest trip. In spite the fact that these men perceived their risk of acquiring HIV infections to be low, over 60% claimed to have used a condom in those sexual encounters. [26]

A number of studies point to a remarkable lack of information about condom utility among the population. In a questionnaire administered to 600 university students  in  Beijing,  just under 50%  of college students,  and  30% of  medical

students did not know that condoms could be effective in the prevention of STIs and HIV infection.[27] In another study in rural China, only 40% of people thought that condoms were effective as a contraceptive and only 12% knew that they were effective in disease prevention.[28]  Other authors too have expressed concern about the low level of understanding of STIs and condoms in rural China.[29] One effort to train staff and integrate prevention of HIV/AIDS education into family planning education showed a significant increase in knowledge and condom use in one rural area (condom use rose from a baseline of 7% to 21%). [30]
 




INDIA[31]
 

Indian health institutions have had long experience in promoting condoms, initially for purposes of family planning and later intensified as the threat of STI/HIV became more evident. There are an abundance of studies and reports on condom use in the many Indian regions, states and communities.  The great regional differences that exist across this large country require caution to avoid the risk of overgeneralizing from local studies.

Condom needs and availability

After years of public education campaigns, knowledge of contraception is nearly universal. Overall, 71% of women currently know about condoms although it is lower in Andrha Pradesh, Madhya Pradesh and Orissaa and may be as low as 50% in Karnatka. [32] Condoms are widely available in both the public and private sector in India. In one relatively recent survey in Mumbai, it was learned that over 75% of people obtained condoms through private medical clinics and commercial stores.[33] The Hindustan Latex Limited (HLL), Thiruvananthapuram reports that its total sales of condoms during 1998-99 were 578.72 million. 

Condom Social Marketing

There are seven different condom social marketing projects in India. Each one concentrates on a different locality with a variety of different products.

(1) The DKT/Bihar Social Marketing Project focuses on populations in Bihar and Madhaya Pradesh States. Begun in 1997, it has sold 15 million condoms (US$0.015 a piece) to date, with most annual sales reported at 9 million.

(2) The DKT/Bombay Social Marketing Project was established in 1993 to develop and market its own brands of condom.

Most recently it has reported cumulative sales of 55 million at a price of US$0.02 a piece.
 

(3) The IPPF/FPAI India Social Marketing Programme, implemented by the Family Planning Association of India (FPAI), began in 1996 and focuses on three predominately rural districts of Madhya Pradesh. It promotes a high quality locally manufactured condom, Sangam, at a cost of $US0.05 a piece. Most recent annual sales are reported at 4.2 million (1997).

(4) The MSI/India I: Social Marketing of Contraceptives began 1997. Implemented by Marie Stopes International (MSI) and supported by KfW, this project concentrates on activities in Calcutta, Rajasthan and Himachal Pradesh through a network of 31 clinics and four mobile units. It reports annual sales of 8.2 million condoms for its two locally producesd brands: Sawan (US$0.023 each) and Milan (US$0.01 each), the latter being promoted for both contraception and disease prevention.  

5) The MSI/India II: Orissa Reproductive Health Project began in 1997 with the support of DfID. Concentrating on low-income populations in Orissa State, it promotes both the Swan brand and Bliss (US$0.035 each).  It reported annual sales in 1998 at 2.58 million condoms.

6) The PSI/India Social Marketing Project, implemented by Population Services International (PSI), has a very wide geographical focus, including, but not limited to Delhi, Punjab and West Bengal. It benefits from support from a number of donors: DfID, KfW, the Futures Group and USAID. In addition to marketing its own brand Masti (US$0.09 for a packet of 4), the project also helps to market the Government of India's Deluxe Nirodh condom (US$0.037 for 5). The project reported cumulative sales of almost 350 million condoms as of 1998.

7) The FUTURES/India Social Marketing Project, supported by USAID and implemented by The Futures Group International-SOMARCIII and Futures Group UK, was in operation between 1994-1998. The project focused its efforts among impoverished urban dwellers in Uttar Pradesh. Condom sales numbered 18.6 million in 1995.[34]

Condom use
 

Condoms are well established as a desirable form of contraception in India. In a recent study of over 8000 potential clients who were given a balanced presentation of all available contraceptive methods, the second most requested method was condoms (9%), though far behind the popular IUD (about 60%).[35]  In Bihar State, however, another study concluded that tubal ligation was the most common method of desired contraception among women surveyed (20.6%) while all reversible forms of contraception (IUD, oral pills and condoms) were used by only 6.8% of women. Earlier studies on condom use in Tamil Nadu (April 94 - March 95) concluded that less than 2% of a representative sample of urban and rural health centres were distributing condoms.

The National AIDS Control Organization consolidated reports from across India regarding the use of condoms in high-risk sexual encounters in 1996.[36]

Condom use in most recent risky sex

general population; 15-49 years, 1996

Area
Proportion Using Condoms

Maharashtra Urban
      62.2

Maharashtra Rural
        9.1




Tamil Nadu Urban
      77.8

Tamil Nadu Rural
        8.6




Delhi/Haryanna Urban
      28.6

Delhi/Haryanna Rural
      25.0




West Bengal Urban
     19.4

West Bengal Rural
     10.0





Reports from the behavioural surveillance surveys in Tamil Nadu (1996, 1997, 1998) showed some fluctuation in reported condom use by female commercial sex workers.

In 1998, 26% reported the use of condoms in their last sexual encounter with a non-regular partner. Focusing on male heterosexual clients at two public STI clinics in Pune between 1993-1997, another team of investigators found that, with 3-month intervals of repeated HIV counselling and testing, consistent condom use rose by 2x (after 6 months) to 3.6x (after 18 months) to 4.7x (after 24 months).[37] 


Injecting drug users (IDUs) in India have also been the subject of concern because of their multiple associations with HIV transmission. In one recent study of 191 IDUs in Manipur, it was found that almost 75% of study subjects were infected with HIV, most within the first two years of injecting. Of concern was the fact that over 65% of study subjects were sexually active, but only 3% consistently used condoms.[38]  



INDONESIA[39]


Despite the fact that surveillance data has generally suggested that Indonesia is a low HIV prevalence country, the condom programme for disease prevention has long been a concern of national pubic health leaders. A number of studies have suggested that condom use in Indonesia has been growing.



Condom use

Data from a 1993 STD prevalence survey among female sex workers revealed that only 5% of brothel-workers and 14% of street-walkers had condoms in their possession[40], while 14-25% of sex workers reported that they had used a condom with their last paying client. In 1994, another study among male clients of FSWs revealed that only 24% had ever used a condom, 8% in an encounter within the last week.[41] A later 1997 study among 600 female sex workers in low-priced brothels in Bali revealed a high level of knowledge of STI/HIV/AIDS and reports that 89% of the women had asked their clients to use condoms and as many as 75% had used condoms the day before the study interview. [42] A related study among 500 male clients of FSWs was not quite as encouraging as reports from the sex workers.[43]  They reported that "about half" of the FSWs female had asked them to use a condom in their most recent visits, and they had complied. It has also been noted that, among villages on Batam Island of Riau, East Sumata, islanders had more positive attitudes about condom use and more knowledge of HIV/AIDS through radio and TV broadcasts.[44]



The 100% condom policy of the Indonesia Ministry of Health was evaluated in 1998 in the Kramat Tunggak Study. [45] This study found that women's continuous condom use was significantly related to their knowledge of STD/AIDS, positive beliefs about condoms and self-efficacy in using condoms.
 

Several studies in Indonesia have focused on the important role that transvestites may play in the spread of STI/HIV. A survey in 1996 showed that more than 50% of  transvestites engaged in
anal sex.  Condoms were used by 88% of those engaging in receptive anal sex and 54% of those engaging in penetrative anal sex.[46] Another study found that transvestites had a mean number of 2-5 partners a week (about 50% of them foreigners) and also had the highest levels of risk behaviour and highest levels of HIV and syphilis seroprevalence documented in Indonesia. Only 29% of transvestites in this study used condoms.[47] Other studies have also pointed at the high risk and generally low condom use of truck drivers and youths, particularly gay youths.[48] [49] [50]





Condom social marketing
 

There are two condom social marketing projects in Indonesia: (1) DKT/Indonesia Social Marketing Project; and (2) FUTURES/HIV/AIDS Prevention Project (HAPP). Beginning in 1996 with support of KfW, the DKT project has developed and promoted its own brand of condoms, especially Sutra. To date it is estimated that over 30,000,000 condoms have been sold with the support of this project. Most recent reported annual sales were 18 million, at a price of US$0.03 a piece. The Futures Group International (FUTURES) also implemented a condom promotion project between 1998-2000 with the support of USAID. This HAPP project targeted high-risk individuals, especially sex workers and sought both to reduce high-risk sexual behaviour through IEC behavioural change and to increase demand for and access to condoms among the target groups.[51]



MYANMAR[52]

Myanmar is recognized as a traditionally reserved and conservative society, with difficulties in communicating openly on issues of reproductive health.[53] As the toll of the HIV/AIDS pandemic made its presence evident in Myanmar, there was recognition that a much more aggressive approach would be needed to promote risk reduction measures, especially the initiation of a condom social marketing programme.

Condom needs and availability

It has been estimated that Myanmar would require approximately 50 million condoms per year if all needs were to be met for family planning and disease prevention. There is no local production of condoms and rules on quality control apply predominately to those purchased by the government agency. Importation of condoms is understood to be about 1 million per year through United Nations donors, 1-3 million per year through the private sector and 7 million per year through NGOs, including the Population Services International (PSI) Condom Social Marketing Programme.  Government health services are reportedly distributing about 1 million condoms per year through their facilities. 

Condom social marketing

PSI is the implementing agency for the PSI/Myanmar Social Marketing Project.  PSI began operations in Myanmar in 1995 with support from a number of donors and a wide variety of local collaborating agencies. Developing and marketing its own condom brand, Aphaw, the project has pursued both family planning and disease prevention goals. A total of over 5 330 493 condoms have been sold through this project. The most recent reported annual sales (1998) were 3 196 165 condoms at a price of US$ 0.028 for a package of four. Starting initially with relatively limited access to mass media, there was a significant shift of marketing strategy in 1998-99 to promote use among target low-income and high-risk groups through community-based distribution agents drawn from local NGOs.[54]



Condom use
 

Myanmar has benefited from an HIV Sentinel Surveillance System that was established in 1992. In 1997, an important advance in that system included the evaluation of behavioural aspects of HIV-related transmission, including condom use. A pilot test of the behavioural component of the Sentinel Surveillance System among 2027 high-risk individuals in Mandalay and Yangon cities revealed a low level of condom use (only 4% of males and 5% of females with STIs, and 33% of commercial sex workers).[55]  More recently, the results of Behavioral Surveillance 2000 have revealed that 70-80% of the population know about condoms for contraception and STI protection and 50% know how to use them properly.

In 2000, Myanmar started a four-city pilot programme promoting 100% condom use. Target groups for this programme are youth, transportation workers, mobile populations and others engaged in high-risk sex. It is anticipated that this programme will be extended nationwide at a later phase.

It is estimated that 2-5% of the population use condoms for family planning.

NEPAL[56]
 

Although reports in the international literature are limited, it is apparent that Nepal has had an active condom promotion programme for many years.

Condom use

In 1993, one study pointed to the differences between three different types of sex workers in Nepal, including the caste-based Badiis, the religion-based Devakiis (temple girls) and residential migrants from India. This study also drew attention to the fact that Badiis sex workers evidenced a somewhat higher use of condoms (10% overall) compared with other sex workers. [57]  An early attempt to promote 100% condom use among several groups of Badiis sex workers was reported to be very successful, although actual changes in condom use in commercial sex were not documented. [58]

A method of promoting condoms through street drama proved widely popular in Nepal and was judged to be a type of programme that was especially suitable for countries with low literacy rates.[59] Another programme in Nepal attempted to upgrade the training of pharmacists in STI care and prevention.[60] Although an evaluation of this programme found good results in the kind of syndromic care provided by pharmacists, and an increase from 14% to 24% of pharmacists who recommended condom use, researchers were discouraged to see that there was no change in the proportion of pharmacists who actually carried and sold condoms.






Condom social marketing

The Futures Group International (FUTURES) - SOMARCH III oversaw the Nepal Social Marketing Project between 1993-1998, which included a variety of family planning materials in addition to condoms. This nationwide project targeted especially high-risk groups and was conducted in collaboration with the Nepal CRS Company and Pariwar Swasthaya Sewa Network (PSSN). Annual condom sales were 6 813 224 in 1998. CRS is reportedly still experiencing annual sales increases and PSSN continues to gain new member service providers.[61]


THE PHILIPPINES[62]

The Philippines remains a low HIV prevalence country. The male condom has been long been recognized by national public health authorities as an invaluable tool to reduce unwanted pregnancies and the spread of sexually transmitted infections. A well developed legal and public health policy framework, increasing attention to the female entertainment industry workers, and vigorous condom social marketing programmes have been at the forefront of national programmes to promote condom use in the country.  Knowledge about and use of condoms has grown significantly in the last decade, although authorities are still concerned by what are perceived as important areas of unmet need.

Condom needs and availability:

Although there does not appear to have been any estimates of needs for condoms nationally, the Department of Health has long been promoting the consistent and correct use of condoms for both disease prevention and fertility regulation. Prior to the 1990s, the distribution of condoms was largely the responsibility of government health clinics and commercial pharmacies; government clinics distributed about 70 -75 % of the 15 million condoms used nationally, about 1% which were used for purposes of family planning.

The Family Planning Organization of the Philippines (FPOP) is a local NGO, which delivers family planning services and commodities throughout the country with support from the International Planned Parenthood Federation (IPPF). The FPOP/IPPF was responsible for distributing about 400 000 condoms per year throughout the 1990s.

The Philippines has a commercial sex industry with both unregistered freelance and registered institution-based female sex workers. The threat of the HIV/AIDS pandemic brought even greater impetus to condom promotion with the initiation of a vigorous condom social marketing programme in 1990.


Condom social marketing
 

There are two condom social marketing projects in the Philippines: (1) DKT/Philippines Social Marketing Project and (2) FUTURES/Philippines Social Marketing Project.  The DKT project, implemented by DKT International and supported by KfW, USAID, PATH and the Japanese Government, was established in late 1990 to focus on both disease prevention and fertility regulation. Its "multiflavoured" (including chocolate and mint flavours) Trust brand condom, at US$0.042 a piece, has seen cumulative sales of almost 110 million.  Most recently, reported annual sales have been almost 21 million (2000).

The Futures Group International (FUTURES) - Somarc III was the implementing agency of a USAID-funded project, between 1993-1998, to work more directly with a variety of private sector industries in the promotion and sale of contraceptive devices and condoms. No particular brand of condom was promoted by this social marketing project which saw itself as associated with the more general growth of over a dozen different brands of nationally produced condoms in the Philippines.[63]

Condom use

Knowledge about and use of condoms has grown significantly in the Philippines since the 1990s. Within a few years after the start of the DKT Condom Social Marketing Project, one study among young men revealed that 98.5% had heard about condoms and over one-third had used them.[64]  About 60% of the population at that time knew about condoms and gained brand recognition through radio, TV and press ads.[65]

Sales of condoms in the Philippines have also grown remarkably over the past decade. From a total of about 15 million condoms distributed in 1990 through the Department of Health, the FPOP/IPPF, the commercial private sector and the DKT Project, the total annual condom market for 1999 was almost 34 million.
It is significant that during this decade the absolute number of condoms distributed by the Department of Health and commercial private sector has declined slightly, while the DKT project has grown greatly to about 60% of total distribution.

Although public knowledge about condoms is high, the consistent use of condoms by groups in special need remains an area of special concern. The use of condoms for family planning purposes has only grown from 1% (1993) to 1.6-2 % (1998).[66],[67]  Interestingly, it has been noted that the conservative "anti-condom, anti-family planning" values of the Catholic church have themselves played only a minor role in the low level of contraceptive use in the Philippines.

Female commercial sex workers are certainly well aware of the value of condoms, although consistent condom use by registered female sex workers has remained fairly constant at about 40% over the last four year (1997-2000). Consistent use has grown slightly among freelance female sex workers, from just over 20% to about 25% in the same period. [68]  Another important recent study found that over 70% of sex workers claimed that they had used a condom in their most recent three preceding commercial sexual relations, although only 6% claimed they used condoms regularly with their regular sex partners.[69]  While some attempt has been made in some areas of the Philippines to enforce a "no condom - no sex” policy in entertainment establishments, one study concluded that the implementation of this policy has not been well evaluated.[70] This same study reported that, in a survey of 26 male commercial sex workers, only 3 abided by the policy in their sexual relationships.




PAPUA NEW GUINEA [71]


Papua New Guinea is experiencing a growing HIV epidemic. Key factors in this increase include widespread high-risk behaviour, high prevalence of other preventable STIs and inadequate services for STI prevention and care. The Government has responded with major new policy initiatives and institution building to improve STI prevention and treatment, including condom promotion. There are serious shortfalls in the supply and distribution of condoms.

Condom needs and availability

In recognition of the need to sigificantly improve condom use and supplies in Papua New Guinea, the National AIDS Council (NAC) has endorsed a policy of 100% Condom Use and Promotion in High-Risk Settings and has identified a four-prong strategy for the social marketing of condoms including:

q  establishing commercial and community channels for the distribution of condoms,

q  linking condom distribution to peer education and family and community awareness programmes,

q  ensuring that condom packaging is attractive and fully informative; and

q  assuring that prices for good quality condoms are at a level affordable to all sectors of the society.

Because there are no manufacturers of condoms in Papua New Guinea, all condom supplies to date have been arranged through commercial and donor imports. Projections of overall needs within the country have not yet been made, although important studies have been conducted to identify major current channels of supply. Most recently, available information has identified that major national distribution channels involve especially

commercial channels: City Pharmacy is a major commercial supplier of condoms through 20 outlets in the country, including four condom vending machines in mines and industry. In 1999, they imported 340 000 condoms.
 

government health system: the Government purchased 3 million condoms in 1999 for free distribution through family planning, STI and other clinics. The community-based distribution  component of the government Women and Child Health Project also distributes contraceptive supplies,  including  condoms,  in  a  six-province
area, covering about 10% of the population. Shortages of supplies, however, are reportedly widespread in the government health system. Eight to 10 million condoms per year are expected to be made available to government supply channels through the AusAID Sexual Health Project.

special projects: A total of 670 000 condoms have been distributed to high-risk groups (sex workers, police, youth) by the IMR Transex Project in Lae and Port Moresby through support by the Government and AusAID. NGOs, like the Salvation Army, YWCA and the Red Cross, are also distributing condoms.

There are as yet no condom standards or quality assurance guidelines for Papua New Guinea. Although most imported project-related condoms appear to follow WHO guidelines, there have been some disturbing problems with commercial supplies being imported with unreasonably close expiry dates.

Condom social marketing

Preparations have been initiated to support social marketing of condoms as part of the Sexual Health Project. The NAC has had a condom logo design and name contest, the results of which may be used as part of a repackaging and marketing campaign.

Condom use
 

The current patterns of condom use in Papua New Guinea have not been well studied. Several older studies suggest that knowledge about and use of condoms is low and complicated by traditional cultural beliefs. One study on the situational contexts in which sex is exchanged by women in Papua New Guinea found that men are generally permitted to "sell" the sexual services of female family members in some areas, a practice that places women at high risk.[72] Women too sometimes sell sexual services to gain financial independence from men. The investigator in this study also uncovered traditional beliefs about alleged dangers that condoms pose to women's reproductive organs and the discouraging effect that this has on condom use.

In a survey of 300 consecutive new attendees in a rural STI clinic, another investigator found that only 9% of patients knew about the role of condoms in disease prevention.[73]


THAILAND[74]

Thailand has long been recognized as a country that has been heavily impacted by HIV/AIDS, epidemiologically linked both to the country’s a robust commercial sex industry and to injecting drug use in some urban centres.  The medical and public health community in Thailand has also long been in the forefront of innovative programmes to promote condom use, initially focused on family planning needs and later in response to the national HIV/AIDS epidemic. The 100% Condom Use Programme, first launched by Thailand in 1989 in Ratchaburi Province and expanded nationally in 1991, has been seen as a principle contributor to the reduction of HIV transmission in the country.

Condom needs and availability

It has been estimated that Thailand needs about 120 million condoms annually for disease prophylaxis (an estimate based on a census of FSWs and by interview data on the average number of clients per day).  There are reportedly five condom manufacturers in Thailand and an additional two commercial outlets repackage imported condoms. Together, these industries are capable of supplying around one billion condoms annually, sufficient for the country to be a significant supplier of condoms to neighbouring countries. Throughout much of its recent past, condoms have been distributed free of charge for both family planning and disease prevention by government medical and public health facilities.  Figures from 1993 show that 71.5 million condoms were distributed nationally (46.5 through the Government and 25 million commercially).[75]

Condom social marketing

The International Planned Parenthood Federation/Planned Parenthood Association of Thailand (IPPF/PPAT) has operated a condom social marketing project in Thailand since 1970. The programme targets low-income families nationwide through a distribution network of community health volunteers/agents, including pharmacists, private clinics, drugstores and industrial factories. Since 1991, the programme has marketed its own brand of

nationally manufactured condoms, PPAT Condoms, that sell for about US$ 0.02 a piece. Distribution of condoms through the condom social marketing project is most recently reported at 800 000 pieces annually.[76]
 

Condom use

In response to indications in 1988-89 that HIV infections were especially high in brothel-based sex workers in Northern Thailand, public health authorities in Ratchaburi Province launched the innovative 100% Condom Programme. The programme required, as a matter of local policy and backed-up by administrative means, that condoms  must  be  used   in   all  brothels  in  the
province.  It was designed to redress the situation where clients could go elsewhere if they confronted a sex work establishment requiring condom use or sex workers insisting on condoms. If all sex establishments followed the same policy of mandatory condom use, clients would have but one choice; no condom - no sex. Within two years, the 100% Condom Programme was expanded nationwide and its results were impressive. By the end of 1994, the percentage of sexual encounters with FSWs that were protected by condoms rose to over 90% (from a preprogramme rate of 14%).[77]  Most recent reviews of Thailand's 100% Condom Programme have credited it with being an "important contributor to large-scale reduction of HIV transmission throughout the country." [78]

Despite the remarkable success of the 100% Condom Programme in Thailand, it has not been a solution to the country's entire STI/HIV problem. In some parts of the country, more efforts at condom promotion are being recommended where studies reveal that STIs and HIV rates remain disturbingly high in both FSWs and their clients. [79] [80] [81]  Condom use rates are still very low among
 

Hmong and Lahu hill tribe people in northern Thailand. [82]  The risk of acquiring STI and HIV are also very high for many married women whose sole risk behaviour appears to be marriage to men who visit FSWs.  More programmes to promote condom use among these women have been recommended.[83] 



VIET NAM[84]

The expanding HIV epidemic in Viet Nam has been linked to sexual transmission and an understanding that commercial sex and preventable STIs have also been increasing. These perceptions have combined to sensitize national policy leaders to a need to give priority to measures to reduce STI/HIV disease transmission risks through condom promotion.

An inadequate supply of affordable and good quality condoms for national programmes and the commercial market appears to be a major impediment.


Condom needs and availability


Year                STI/HIV prevention                Family planning          Total
                                                                                                            million

2000                            129                                          80                    209
2001                            152                                          86                    238
2002                            178                                          91                    269

 
A national condom audit has made estimates of condom needs for Viet Nam for both fertility regulation and disease prevention:

Somewhat controversial estimates suggest that the number of condoms needed in Viet Nam in 2005 may be as high as 140 million for family planning and 61 million for disease prevention purposes. In the year 2000, the total supply of condoms available nationally was 90 million: 17 million for free distribution, 45 million for the condom social marketing programme and 25-30 million imported in the private sector (mainly smuggled).

There are two factories in Viet Nam (MERUFA and LAPRODEX) that produce condoms. Although national condom production is generally of excellent "international standard" quality, the combined capacity of production is short of growing needs. MERUFA has a capacity to produce 72 million condoms per year, although its 2001 production will probably only be 30 million. LAPRODEX, on the other hand, is expecting to produce 60 million condoms this year, nearly its full capacity.  Half the LAPRODEX production output will go to the DKT Condom Social Marketing Project.

Viet Nam benefits from significant international support in meeting condom needs. Recent planned or completed international donations include:

(1)   US$200 000 from UNFPA to the National Committee for Population and Family Planning (NCPFP) for condom purchase;

(2)   500 000 condoms from the Republic of Korea, through UNFPA; and

(3)   US$440 000 from The Government of Denmark for procurement of 20 million locally procured condoms, half for free distribution through the public sector and half for distribution by the DKT Social Marketing Project.

Although these contributions are extremely important and helpful, national leaders remain concerned with projections that Viet Nam may require as much as US$ 68 million to meet national demands for condoms by the end of 2007.

The NCPFP is responsible for ensuring condom availability and distribution. Their system for purchase and distribution of condoms is well developed. However, insufficient national supplies have left shortfalls throughout the health

care system, especially inadequate availability of free condoms for those in need. Recent changes in NCPFP policy have curtailed the distribution of free condoms at family planning clinics. STD clinics also do not distribute condoms to patients.
 

Condoms are widely available in the commercial marketplace. National condom manufacturers produce some brands for commercial distribution and there are a variety of both legally and illegally imported brands, many of questionable quality. Commercially available condoms generally cost between US$0.35 and US$0.95 a piece, depending upon country of origin and assumed quality.

Condom social marketing

DKT International has overseen a condom social marketing programme in Viet Nam since 1993. It has developed and marketed two brands of condoms, "OK" and "Trust", with a recommended sale price of $US 0.04 and $US 0.07 for a packet three. A variety of innovative retail training and promotional programmes have supported the sale of these distinctive brand names. Using more than 7500 retail outlets, DKT claims its brands have sold over 140 million condoms to date, with current annual sales of 41 million. Donors to the DKT programme in Viet Nam include the World Bank, the Government of Finland, USAID, KfW and the Packard Foundation.[85]

Condom use

Despite the great perception of need and considerable national efforts, it is widely agreed by both national health authorities that condom use in Viet Nam remains disturbingly low.

It is estimated that condoms are used as a contraceptive method by only 6% of married couples.

A relatively recent study of STI clinic male attendees[86] revealed that almost 75% had visited a commercial sex worker (CSW) in the previous three years. Although 37% of men claimed they had used a condom in their most recent intercourse, only 7% reported they used condoms regularly, and 70% apparently had never used condoms. 


In a study in rural Viet Nam among 70 men in what was characterized as a "thriving underground Gay culture", researchers found that despite the high prevalence of risky sexual contacts, only one man had ever used a condom.[87]
 

In view of the importance of pharmacies in health care in Viet Nam, and the growing commercial distribution of condoms, attention was given in one recent study to how persons presenting with STI
symptoms were handled.[88] Although antibiotics were provided to 85% of planted trained researchers presenting with a complaint of urethral discharge, in only 1% of cases were these alleged clients advised to practice safe sex. Questioning pharmacy employees after these encounters about their understanding of STI prevention and care revealed a knowledge base much different from their observed behaviour. Only 7%, however, said they would ever recommend using a condom to a person with an apparent STI.

A thorough review of the evolving HIV epidemic in Viet Nam has concluded that immediate and intensive prevention programmes in high-risk groups, including improving the availability of condoms, may serve to decelerate the spread to the broader population.[89] 




[1] Bangladesh, Cambodia, China, India, Indonesia, Myanmar, Nepal, The Philippines, Papua New Guinea, Thailand and Viet Nam

[2] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[3] Vermund SH.  Factors driving the HIV pandemic: the example of Asia. Conf Retroviruses Opportunistic Infect, 1996 Jan 28-Feb 1;3rd:176
[4] Khawaja ZA; Gibney L; Vermund S.  What is known about HIV/AIDS and its risk factors in two Muslim Countries: Pakistan and Bangladesh.  Int Conf AIDS, 1996 Jul 7-12;11(1):144 (abstract no Mo.C.1514)
[5] Akther S. A study on knowledge and attitude regarding HIV infection among prostitutes of Narayangonj-Bangladesh. Int Conf AIDS, 1996 Jul 7-12;11(2):510 (abstract no Pub.D.1468)
[6] Begum A et al.  Effectiveness of peer education and monitoring of the condom use by the sex workers in brothel settings in Bangladesh for preventive HIV.  Int Conf AIDS,  1998;12:692 (abstract no 532/33521)
[7] Adhikary SS et al.  Condom promotion success through peer educator; an effective strategy in Faridpur brothels by Shapla Mahila Samity. Int Conf AIDS, 1998;12:700 (abstract no 33566).

[8] Jenkins C. Varieties of homosexuality in Bangladesh: implications for HIV prevention.  Int Conf AIDS, 1998;l12:244-5 (abstract 155?14312)
[9] Islam N.  Adolescents and AIDS: a study of awareness and attitude concerning HIV & AIDS in the Manikganj District of Bangladesh.  Int Conf AIDS,  1998:12:916 (abstract no 43353)
[10] Global directory of condom social marketing projects and organizations. UNAIDS, January 2001
[11] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[12] Cambodia's Behavioral Surveillance Survey 1999, National Center for HIV/AIDS, Dermatology and STD, Ministry of Health of the Kingdom of Cambodia. Phnom Penh, 2000. In: Sopheap S. Contributions of STD intervention among sex workers and their clients in the prevention of HIV infection in Cambodia. Thesis for Master of Science in Disease Control, Prince Leopold Institute of Tropical Medicine  (IMTA/MCM-MDC/CO2), 2000 No. 33, Antwerp 2000.
[13] Op cit. Ref. 10:11
[14] Sopheap S. Contributions of STD intervention among sex workers and their clients in the prevention of HIV infection in Cambodia. Thesis for Master of Science in Disease Control, Prince Leopold Institute of Tropical Medicine  (IMTA/MCM-MDC/CO2), 2000 No. 33, Antwerp 2000.
[15] Thuermer K et al.  Cambodians respond to "Number One" Condom Social Marketing Campaign.  Int Conf AIDS, 1996 Jul 7-12;11(1):411 (abstract no Tu.D.2883)
[16] Burkly M.  Sales Training in a Cambodian CMS Program: A Way to Increase Condom Use?  Int Conf AIDS,  1996 Jul 7-12;11(2):237 (abstract no TH.C.4468)
[17] Pichith K et al.  Aspects of epidemiological and clinical manifestation of adult HIV/AIDS patients at Calmette Hospital in Cambodia.  Annu Conf Australas Soc HIV Med, 1997 Nov 13-16;9:103 (abstract no IS109)
[18] Prybylski D, Alto WA. Knowledge, attitudes and practices concerning HIV/AIDS among sex workers in Phnom Penh, Cambodia.  AIDS Care, 1999 Aug;11(4):459-72
[19] Morio S et al.  Sexual behavior of commercial sex workers and their clients in Cambodia. Japan-Cambodia Calloborating Research Group. J Epidemiology, 1999 Jun;9(3):175-82
[20] Unless otherwise indicated, information in this report has been abstracted from correspondence between the Ministry of Health and WHO/WPRO (especially the Draft Condom Situation in China, An Initial Situation Assessment).
[21] Op cit. Ref. 10:11
[22] Liu H et al.  A study of sexual behavior among rural residents of China.  J Acquir Immune Defic Syndr Hum Tretrovirol, 1998 Sept 1;19 (1):80-8
[23] Changgeng S, Wenyan X, Ganyun Y. China.  In: Brown T et al, eds. Sexually transmitted diseases in Asia and the Pacific. Australia, Venereology Publishing Inc, 1998:73-85
[24] Lo KK, Lee SS, Wong KH.  Condom use among female commercial sex workers and male clients in Hong Kong.   Int Conf AIDS, 1994 Aug 7-12:10 (2):286 (abstract no PC0523)
[25] Wong KH et al.  Condom use among female commercial sex workers and male clients in Hong Kong.  Int J STD AIDS,  1994 Jul-Aug; 5 (4); 287-9
[26] Lau JT, Thomas J. Risk behaviours of Hong Kong male residents travelling to mainland China; a potential bridge population for HIV Infection. AIDS Care, 2001 Feb; 13(1): 71-81
[27] Cheng Y, Lu YU, Ren LI.   AIDS and condoms - knowledge & attitudes of students.  Int Conf AIDS, 1998; 12:184 (abstract no 13495).
[28] Liao SS et al.  Unexpectedly low awareness of AIDS, STDs and condoms among Dai Ethnic Minority villagers in China's Yunnan Province.   Int Conf AIDS, 1996 Jul 7-12; 11(2): 52 (abstract no. We.D.483)
[29] Liao SS et al. Extremely low awareness of AIDS, sexually transmitted diseases and condoms among Dai Ethnic villagers in Yunnan Province.  China AIDS, 1997 Sept; 11 Suppl 1:S27-34.
[30] Wu Z et al. Integrating AIDS prevention into the Family Planning Programme in Southern Yunnan, China.   Int Conf AIDS, 1998; 12:167  (abstract no. 360/13403)
[31] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[32] Annual Report 1999-2000.  New Delhi, India, Ministry of Health And Family Welfare (as cited in Hindustan Lates Limited (HLL), Thiruvananthapuram).
[33] National Family Health Survey (NFHS-2), 1998-1999, Mumbai, India, International Institute for Population Sciences (as cited in Hindustan Lates Limited (HLL), Thiruvananthapuram).
[34] Global Directory of Condom Social Marketing Projects and Organizations, UNAIDS, January 2001
[35] Baveja  R et al.  Evaluating contraceptive choice through the method-mix approach. An Indian Council of Medical Research (ICMR) task force study.  Contraception 2000 Bef, 61(2): 113-9.
[36] UNAIDS/WHO Epidemiological Fact Sheet, 2000 Update : 9.
[37] Bentley ME et al. HIV testing and counseling among men attending sexually transmitted disease clinics in Pune, India: changes in condom use and sexual behavior over time.  AIDS, 1998 Oct 1; 12(14): 1869-77
[38] Eicher AD et al. AIDS Care 2000 Aug 12(4): 497-504.
[39] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[40] Joesoef MR et al.  Determinants of condom use in Female Sex Workers in Surabaya, Indonesia.  Int J STD AIDS, 2000 Apr; 11(4): 262-5.
[41] Fajans P, Ford K, Wirawan DN.  Factors related to condom use by clients of female sex workers in Bali, Indonesia.  Int Conf AIDS, 1994 Aug 7-12; 10(2): 324 (abstract no PD0476).
[42] Ford K et al.  AIDS/STD knowledge, preventive practices, condom use and STD prevalence among female sex workers in Bali, Indonesia.  Int Conf AIDS, 1998; 12:446 (abstract no 23523).
[43] Ford K et al.  AIDS/STD knowledge, preventive practices, condom use and STD prevalence among male clients of female sex workers in Bali, Indonesia.  Int Conf AIDS, 1998; 12:1029 (abstract no 60168).
[44] Shirin L, Wagner T.  Considering cultural backgrounds when establishing a sexuality education programme.  Inf Conf AIDS, 1998; 12:248 (abstract no 14328).
[45] Ingshi-Mamahit ES. 100% condom policy in brothel complexes in Indonesia: lessons learned from Kramat Tunggak Study.  Int Conf AIDS, 1998; 12:900 (abstract no 43268).
[46] Prihaswan P, Laurel M.  Transvestites' potential role as a core community in AIDS spread.  Int Conf AIDS, 1998; 12:370 (abstract no 23147).
[47] Lubis I et al.  HIV prevalence and risk behavior among male transvestites in Jakarta, Indonesia.  Int Conf AIDS, 1998; 12:367 (abstract no 23131).
[48] Muliawan P, Wirawan DN, Sutakertya IB.  STD/HIV/AIDS education, condom promotion/distribution and STD services for truckers in Bali, Indonesia.  Int Conf AIDS, 1996 Jul 7-12:11(2); 474 (abstract no Pub.C.1232).
[49] Merati T et al. HIV risk taking among youth participating in peer-led AIDS education programs in traditional Balinese youth groups.  Int Conf AIDS, 1996 Jul 7-12; 11(2): 230 (abstract no Th.C.4411).
[50] Priyadi P, MacLaren L.  Evaluating risk reduction strategies for Gay youth.  Int Conf AIDS, 1996 Jul 7-12; 11(2): 39 (abstract no. We.C.443).
[51] Op cit. Ref. 10:11
[52] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation Assessment on Condom Situation."
[53] Honeyman SW et al.  Strategies for change: condom social marketing for HIV/AIDS in Myanmar (Burma).  Int Conf AIDS, 1998:12:676 (abstract no 33433).
[54] Op cit. Ref. 10
[55] Zaw M et al.   Preliminary Findings of Behavior Sentinel Surveillance for HIV Risk Behaviors - 1997. Int Conf AIDS, 1998; 12:935 (abstract no 43456).
[56] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[57] Gurubacharya VL, Suvedi BK.  Focus Group discussions and condom promotion in Nepal.  Int Conf AIDS, 1993 Jun 6-11l9(2); 776 (abstract no PO-C35-3352).
[58] Bhatt P, Baltes R. 100% condom use for Badiis sex workers in Nepal.  Int conf AIDS, 1994 Aug 7-12:10(2): 13 (abstract no 345D).
[59] Singh M.  Harm reduction and street-based programs: looking into Nepal.  Subst Use Misuse, 1998 Apr: 33(5): 1069-74.
[60] Taladhar SM et al.  The role of pharmacists in HIV/STD prevention: evaluation of an STD syndromic management intervention in Nepal.  AIDS, 1998; 12 Suppl 2:S81-7.
[61] Op cit. Ref. 10
[62] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[63] Op cit. Ref. 10, supplemented by updated direct information from the DKT/Philippines Condom Social Marketing Project.
[64] Jimenez and Lee. Sexual risk behavior and HIV/AIDS: a survey of Filipino males in three Philippine cities." (as cited in the Situation assessment, page 27).
[65] Survey on condom usage and attitudes in the Philippines.  Manila,  AV Research, Aug 1994 (as cited in the Situation assessment, page 32).
[66] 1998 NDHS. National Statistics Office (as cited in the Situation assessment, page 8).
[67] Southeast Asian populations in crisis, challenges to the implementation of the ICPD Programme of Action. UNFPA and The Australian National University (ANU), December 1998 (as cited in the Situation assessment, page 9).
[68] Behavioural sentinel surveillance results: 1997-2000, Field Epidemiology Training Program. Department of Health (as cited in the Situation assessment, page 27).
[69] Evaluation of risk assessment in the diagnosis of STI/RTI among female sex workers. Manila, UP-PGH-STI/RTI Study Group, 2000.
[70] Morisky DE et al. The effect of establishment practices, knowledge and attitudes on condom use among Filipina sex workers.  AIDS Care, 1998; 10:213-220
[71] Unless otherwise indicated, information in this report is derived largely from a recent trip report by WPRO staff to Papua New Guinea and from complementary information supplied by national staff in response to a "Condom situation assessment" questionnaire.
[72] Jenkins CL.  Sex as work in Papua New Guinea. Int Conf AIDS,  1994 Aug 7-12; 10(2): 325 (abstract no PD0481).
[73] Kramer PB.  Knowledge about AIDS and follow-up compliance in patients attending a sexually transmitted disease clinic in the Highlands of Papua New Guinea.  PNG Med J,  1995 Sep; 38(3); 178-90.
[74] Unless otherwise indicated, information for this report was provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[75] Rojanapithayakorn W Hannenberg R. The 100% Condom Program in Thailand.  AIDS, 10:1-7 1996; pp 4
[76] Global Directory of Condom Social Marketing Projects and Organizations, UNAIDS, January 2001 supplemented by updated direct information from the DKT/Philippines Condom Social Marketing Project.
[77] Ibid; Rojanapithayakorn et al, pp 1
[78] Evaluation of the 100% Condom Programme in Thailand, UNAIDS Case Study, July 2000
[79] Tabrizi SN et al.  Prevalence of sexually transmitted infections among clients of female commercial sex workers in Thailand. Sex Transm Dis, 2000 Jul; 27(6); 358-62
[80] Limpakarnjanarat K et al.  HIV-1 and other sexually transmitted infections in a cohort of female sex workers in Chiang Rai,
Thailand.. Sex Transm Infect, 1999 Feb; 75(1): 30-5.
81 Kilmarx PH, et al.  Seroprevalence of HIV among female sex
workers in Bangkok; evidence of an ongoing infection risk after the












"100% condom program" was implemented.  J Acquir Immune Defic Syndr, 1999 Aug 1;21(4): 313-6.
[82] Omori K. [Knowledge about AIDS and risk behaviors among hill tribes in northern Thailand] Nippon Koshu Eisei Zasshi, 1999 Jun; 46(6): 466-75 .
[83] Xu F et al.  HIV-1 Sero-prevalence, risk factors, and preventive behaviours among women in northern Thailand. J Acquir Immune Defic Syndr,2000 Dec 1; 25(4): 353-9
[84] Unless otherwise indicated, information for this report was generally provided by the WPRO Country Office, especially through their responses to questions posed in a "Situation assessment on condom situation."
[85] Op cit. Ref. 10
[86] Thuy NT et al.  Predictors of visits to commercial sex workers by male attendees at sexually transmitted disease clinics in southern Viet Nam.  AIDS, 1999 Apr 16; 13(6): 719-25.
[87] Wilson DW, Cawthorne P. Helping gay men in a provincial Vietnamese town to protect themselves from AIDS.  In Conf AIDS, 1998:12:913 (abstract no. 43334).
[88] Chalker J et al. STD management by private pharmacies in Hanoi: practice and knowledge of drug sellers.  Sex Transm Infect, 2000 Aug; 76(4): 299-302.
[89] Quan VM et al.  HIV in Viet Nam: The evolving epidemic and the prevention response, 1996 through 1999.  J Acquir Immune Defic Syndr, 2000 Dec 1; 25(4): 360-9.

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