WORLD HEALTH ORGANIZATION
Regional Office for South-East Asia
Regional Office for the Western Pacific
 |
The Condom Situation Assessment in
11 Asian and Western Pacific Countries[1]
 |
|||
 |
|||
The Condom
Situation Assessment in 11 Asian and Western Pacific Countries
 |
Introduction 2
I: Overview 3
Bangladesh 9
Cambodia 11
China 14
India 18
Indonesia 22
Myanmar 25
Nepal 27
The Philippines 29
Papua New Guinea 32
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]
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
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]
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 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 marketingThe 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 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 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.
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 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] 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
|
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.
