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Targeting populations at increased infection risk: condom promotion remains an important HIV prevention measure.

Traditionally, efforts to prevent HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States.  infection by promoting condom use--as part of a comprehensive array of risk-reduction approaches--have targeted individuals at increased risk of infection. One such targeted population is sex workers based in brothel establishments, as well as those based in non-brothel establishments (where condom use often is low). The second is men, since they often make the final decisions on condom use in sexual relations sexual relations
1. Sexual intercourse.

2. Sexual activity between individuals.

Sex work in non-brothel establishments such as restaurants, bars, and massage parlors is so common in many settings that a variety of interventions are attempting to reach these populations with condom use messages. (Notably, while it is recognized that many social, cultural, and economic conditions foster commercial sex work, FHI FHI Family Health International
FHI Fuji Heavy Industries Ltd
FHI Food for the Hungry International
FHI Florida Hydrogen Initiative, Inc. (Tallahassee, Florida) 
 and similar organizations are unable to eliminate these conditions. Rather, FHI intervenes to help such women protect themselves from acquiring or transmitting HIV/STIs and prevent unplanned pregnancy.)

A Dominican Republic Dominican Republic (dəmĭn`ĭkən), republic (2005 est. pop. 8,950,000), 18,700 sq mi (48,442 sq km), West Indies, on the eastern two thirds of the island of Hispaniola. The capital and largest city is Santo Domingo.  condom promotion intervention highlighted in this issue (see article, page 9) involves sex workers employed in both brothel and non-brothel establishments. Meanwhile, FHI is conducting an intervention targeting female employees of two Asian-based breweries who supplement their income with sex work.

"Female beer promoters, who serve beer to customers in restaurants, are paid little and are under constant pressure to either meet sales targets or lose income," says Michael Merrigan, senior program officer in FHI's Cambodia office. "They are in close contact with customers, and many supplement their meager mea·ger also mea·gre  
1. Deficient in quantity, fullness, or extent; scanty.

2. Deficient in richness, fertility, or vigor; feeble: the meager soil of an eroded plain.

 income by having sex with customers after hours Adv. 1. after hours - not during regular hours; "he often worked after hours" ." To help these women protect themselves against HIV/STIs, FHI offers a comprehensive prevention approach that includes peer education, building relationships with establishment owners to facilitate women's access to HIV/STI education and services, STI STI systolic time intervals.  services delivered at beer promoters' homes, as well as condom promotion.

FHI's work with female beer promoters is part of a larger program that regularly targets both brothel-based and non-brothel-based sex workers in Cambodia for HIV/STI outreach education. FHI's HIV/STI prevention and care activities with non-brothel-based sex workers also focus on women working in such establishments associated with commercial sex as karaoke beer gardens, massage parlors, and guest houses/hotels. FHI-supported interventions include outreach and peer education to provide information and behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness.  messages about HIV/STI prevention, provision of and referral to STI treatment services, and condom promotion. And, as more sex workers have learned their HIV status, FHI has begun to address care, treatment, and support issues for this group.


Use of a wide array of HIV/STI prevention strategies holds the most promise for reducing the spread of these infections. FHI both promotes and implements what it calls an "ABC ABC
 in full American Broadcasting Co.

Major U.S. television network. It began when the expanding national radio network NBC split into the separate Red and Blue networks in 1928.
 to Z" model: abstinence, be faithful to one partner, or--if "A" or "B" cannot be achieved--use condoms. These three strategies can be further complemented by a number of other effective HIV prevention approaches; that is, the "to Z" component of the "ABC to Z" model. (See article, page 3.) Although condom use is an important element of this comprehensive approach, men often express a dislike for condoms and are particularly likely to abandon condom use with regular partners, whom they assume are not infected with HIV/STIs. In Thailand, young men are decreasing their patronage of brothel-based sex establishments, (1) but they are increasingly engaging in unprotected sexual relationships with female peers. (2) A 2001 study found that two-thirds of 5,646 young men inducted into the Royal Thai Army The Royal Thai Army is the army of Thailand. It is the oldest and largest branch of the Royal Thai Armed Forces. The army was formed in 1874 , partly as a response to new security threats following the Bowring Treaty with Britain, which opened up the country for international trade.  in May 1999 had sex with a girlfriend within the past year, but just 13 percent used a condom. (3) Research also indicates that some young men continue to buy sex in informal venues while concurrently having unprotected sex Unprotected sex refers to any act of sexual intercourse in which the participants use no form of barrier contraception. Sexually transmitted infections
Specifically, unprotected sex
 with female peers. (4) This puts their presumably pre·sum·a·ble  
That can be presumed or taken for granted; reasonable as a supposition: presumable causes of the disaster.
 low-risk, regular partners at high risk of infection.

The vulnerability to HIV infection of presumably low-risk individuals is also illustrated in a modeling exercise, conducted in Cambodia with assistance from FHI. In 2002, the Cambodia Working Group on HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome  Projection estimated that almost half of new infections in the country that year were transmitted between husbands and wives. (5)

Given that men often make the final decision on condom use in sexual relations, attempting to increase their condom use is a challenge that reproductive health workers continue to address.

In Harare, Zimbabwe, FHI researchers and in-country collaborators began to explore in 2002 whether partners of 344 women (who had been through a two-month condom promotion intervention) felt more comfortable learning about condom use in all-male group sessions or in couple sessions with their regular partners. Preliminary results from this randomized ran·dom·ize  
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment.
 trial show that a similar and unexpectedly high proportion of men (about 40 percent) attended condom promotion sessions when invited, regardless of type of session.

"That level of male involvement is much higher than expected and is encouraging in terms of getting males involved in condom promotion activities via their regular partners," says Dr. Markus Steiner, an FHI senior epidemiologist who helped design the study. "We think our results show that, in a country like Zimbabwe where there is a very good existing family planning family planning

Use of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources.
 infrastructure, it is possible to get men more involved in a family planning setting."

Meanwhile, a review of operations research operations research

Application of scientific methods to management and administration of military, government, commercial, and industrial systems. It began during World War II in Britain when teams of scientists worked with the Royal Air Force to improve radar detection of
 in 13 countries found that having men promote condoms through community-based distribution (CBD (Component Based Development) Building applications with components (objects). See component software.

CBD - component based development
) programs can increase not only the total number of condoms that programs distribute, but also the number dispensed to male clients. (6) The report highlighted research in Peru that found that male CBD workers with the Promocion de Labores Educativas y Asistenciales en Favor de la Salud (PROFAMILIA) CBD program in Lima sold twice as many condoms per month as did female CBD workers: a median of 49 condoms and 24 condoms per month, respectively. The Peruvian study found similar performance patterns among workers in the Centro NorPeruano de Capacitacion y Promocion Familiar (CENPROF) CBD program in Trujillo, (7) as did a 1995 study among CBD volunteers in the Kilifi district of Coast Province, Kenya. Fifteen male CBD volunteers in the Kilifi district each distributed approximately 9,550 condoms during the 18-month study period, while 15 female CBD volunteers in the same district each distributed approximately 3,523 condoms. (8) Both studies adjusted for other factors that could influence worker performance, including education, occupation, marital status marital status,
n the legal standing of a person in regard to his or her marriage state.
, training, length of time in the program, and CBD post location.

Having men promote condoms through CBD programs may require adjustments in attitudes, recruitment methods, and training schedules. The Peruvian study found that female program managers never fully accepted men in the CBD program and that, in spite of male CBD workers' high productivity, female managers continued to have doubts about the men's work. "Men have less free time to do the work," one manager observed. Another commented, "Men produce less." Such attitudes may have contributed to the fact that female CBD workers replaced male counterparts who left the program. (9) Research in Tanzania found that men in some communities initially had reservations about male CBD workers distributing condoms and other contraceptives to their wives, although they changed their views after becoming more familiar with the program. (10)

While recruiting men into CBD programs can be difficult, research has found that CBD training curricula do not need to be markedly altered to accommodate male workers. (11) Only the timing of sessions may need to be changed. In Peru, both the PROFAMILIA and CENPROF CBD programs scheduled training on weekends to accommodate men's work schedules. (12)


In the effort to encourage condom use among men, researchers are studying whether offering them a choice of male condoms increases rates of use and decreases STI rates. FHI researchers are conducting randomized controlled trials in Jamaica, Ghana, Kenya, and South Africa to explore this idea. (13)

In Kingston, Jamaica, FHI is studying condom preferences of 1,000 men attending the capital's largest STI clinic for treatment of urethral urethral

pertaining to or emanating from urethra.

urethral agenesis, urethral atresia
failure of development of all or part of the urethra: characterized by complete urine retention. A rare cause of neonatal uremia.
 discharge. Half of the men will be offered only the standard condoms distributed at the clinic. The other group will be offered Rough Rider Rough Rider

Member of the 1st Volunteer Cavalry regiment in the Spanish-American War. The group, organized and led by Theodore Roosevelt and Leonard Wood, included cowboys, miners, policemen, and college athletes.
 condoms, designed with ribbed "pleasure bumps"; Inspiral condoms, which have a loose-fitting shape to enhance sensation; standard condoms issued by the U.S. Agency for International Development (USAID USAID United States Agency for International Development
USAID Agencia de los Estados Unidos para el Desarrollo Internacional (Spanish) 
); and standard clinic condoms. At study enrollment, the men are being screened and treated for gonorrhea gonorrhea (gŏnərē`ə), common infectious disease caused by a bacterium (Neisseria gonorrhoeae), involving chiefly the mucous membranes of the genitourinary tract. , trichomoniasis trichomoniasis (trĭk'əmənī`əsĭs), sexually transmitted disease caused by the parasitic protozoan Trichomonas vaginalis. , and chlamydial chlamydial

pertaining to members of the family Chlamydiaceae.

chlamydial abortion
abortion in cows, ewes, sows and goat does caused by Chlamydophila abortus and C. pecorum. See enzootic abortion of ewes.
 infection. Screening for these STIs will continue at regular intervals during this six-month study. Structured individual interviews are being conducted at each study visit to learn about condom use and selection. Data collection is expected to be complete in July 2004.

"If we find that providing a choice of condoms has no impact on self-reported use and STI incidence, then programs should just provide the least expensive condom available and not spend resources providing slightly more expensive condoms with fancy packaging or features to enhance pleasure, such as ribs or a looser fit," says FHI's Dr. Steiner, the study's principal investigator. "However, if we find that choice increases condom use and decreases STI rates, then providing a choice is an intervention that could be easily replicated elsewhere."

FHI's condom choice trials in Ghana, Kenya, and South Africa are similar to the trial in Jamaica, except that only self-reported condom use data are being collected. In all three sites, men assigned to a "choice" group are being given their selection of four condoms: Rough Rider, Inspiral, USAID-issued, or each country's socially marketed condom. Men in a "no-choice" group are being offered only the USAID condom.

The studies in Ghana and South Africa are yielding interesting early findings. FHI researchers have noted that study participants are selecting the Rough Rider as their first choice and the Inspiral and the socially marketed condoms as their second choices. "The interesting thing is that in both countries, the socially marketed condoms are essentially the same as the USAID condoms--they are just packaged differently," says Carol Joanis, an FHI associate director and the principal investigator of the studies in Ghana, Kenya, and South Africa. Joanis plans to conduct focus groups with study participants to find out reasons for their condom selections.

"We need to know why participants like particular condoms," Joanis says. "Do they prefer condom attributes, like the bumps and ridges? Are they attracted to a condom based on the way it was promoted? Or, do they simply like the color of the packaging?"


(1.) Nelson KE, Eiumtrakol S, Celentano DD, et al. HIV infection in young men in northern Thailand, 1991-1998: increasing role of injection drug use. J Acquir Immune Defic Syndr 2002;29(1):62-68; Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life.  and a decline in HIV infection among young men in Thailand. N Engl J Med 1996; 335(5):297-303.

(2.) VanLandingham M, Trujillo L. Recent changes in heterosexual attitudes, norms and behaviors among unmarried Thai men: a qualitative analysis Qualitative Analysis

Securities analysis that uses subjective judgment based on nonquantifiable information, such as management expertise, industry cycles, strength of research and development, and labor relations.
. Int Fam Plann Perspect 2002; 28(1):6-15; Saengdidtha B, Ungchusak K. Sexual behaviours and sexually transmitted diseases Sexually transmitted diseases

Infections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely
 among young Thai men in 1999. Venereology venereology /ve·ne·re·ol·o·gy/ (-ol´ah-je) the study and treatment of venereal diseases.

The study of sexually transmitted diseases.

(3.) Saengdidtha.

(4.) VanLandingham.

(5.) The Cambodia Working Group on HIV/AIDS Projection. Projections for HIV/AIDS in Cambodia: 2000-2010. Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STDs, 2002.

(6.) Population Council. Program Brief No. 2. Using Men as Community-Based Distributors of Condoms. Washington, DC: Frontiers in Reproductive Health, Population Council, 2002.

(7.) Foreit JR, Garate MR, Brazzoduro A, et al. A comparison of the performance of male and female CBD distributors in Peru. Stud Fam Plann 1992;23(1):58-62; Population Council.

(8.) Family Planning Association This article is about the UK charity. For the Hong Kong organisation, see The Family Planning Association of Hong Kong.

The Family Planning Association, also known as fpa, is a UK registered charity (number 250187) working to promote sexual health.
 of Kenya and Population Council/Africa OR/TA Project. Increasing Male Involvement in the Family Planning Association of Kenya (FPAK FPAK Family Planning Association of Kenya
FPAK Federação Portuguesa de Automibilismo E Karting (Portugal)
FPAK Flat Package
) Family Planning Program. Nairobi, Kenya: Population Council, 1995.

(9.) Foreit.

(10.) Chege J, Rutenberg N, Janowitz B, et al. Factors Affecting the Outputs and Costs of Community-Based Distribution of Family Planning Services in Tanzania. Nairobi, Kenya: Population Council, 1998; Population Council.

(11.) Family Planning Association of Kenya and Population Council/Africa OR/TA Project; Foreit.

(12.) Foreit.

(13.) Steiner M. Update--condom choice initiative. Annual meeting of the FHI Technical Advisory Committee, Contraceptive Technology and Family Planning Research, Chapel Hill, NC, May 2, 2002.
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Author:Smith, Emily J.
Date:Jun 22, 2003
Previous Article:The "ABC to Z" approach: condoms are one element in a comprehensive approach to HIV/STI prevention. (Introduction).
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