Barriers to Condom Access: setting an advocacy agenda - ICASO Advocacy Briefing

8/2/2019 Barriers to Condom Access: setting an advocacy agenda - ICASO Advocacy Briefing

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Barriers to Condom Access:

setting an advocacy agenda

ICASO Advocacy Briefing

Contents:

Methodology 2

HIV Prevention & Condoms 2

Condom Access Barriers: 4

1. Socio-Cultural 4

2. Legal & Policy 10

3. Economic & Financial 14

4. Structural 19

Next Steps 24

Writers: Jenny Drezin, Mary Ann Torres (ICASO) and Kieran Daly (ICASO).We are grateful for the extensive input from Franck Derose, Melissa Ditmore, Kate Hawkins, Andrew Hunter,Khadija Moalla, Tim Thomas, Alejandra Trossero, and many other community advocates. We are also gratefulfor the financial support provided by Population Action International (PAI). The views expressed within thispublication do not necessarily represent the views of PAI or the contributors.

Header Photo AIDS Committee of Toronto

It is the right of people living with HIV and those most at risk andvulnerable to HIV infection to access comprehensive services andcommodities. This includes proven prevention approaches suchas the promotion and use of condoms. However, the failure toremove barriers that determines whether a person can accessand use a condom is one of the biggest impediments to pre-venting millions more HIV infections.

Frontline community research supported by ICASO in fourteencountries has provided analysis of some of these barriers tocondom access. In particular, it is clear that governments anddonors around the world need to commit new resources andenact and reform legislation, policy and programming that willensure condom access and availability. A mobilized communitysector that can forcefully advocate for condom access is needednow more than ever.

Peer educator condom demonstration, South Africa Students Partnership Worldwide


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ThisAdvocacy Briefing provides ananalysis of some of the barriers to condomaccess based on the findings from front-line community research supported byICASO. This information was sourcedfrom a community-led monitoring projectundertaken in 2005 and 2006 assessingthe implementation of the United NationsGeneral Assembly Special Session on

HIV/AIDS (UNGASS) Declaration ofCommitment on HIV/AIDS1.

Community groups from 14 countries2

collected and analyzed data and informa-tion on the broad response to HIV and

AIDS, preparing country reports of thefindings and the critical issues for com-munities in their country. In relation tocondom access, most of the analysisfocused on male condoms, with somecommunity researchers including issuesaround female condoms.

Given that this document relies mainly

on this community analysis, it does notpurport nor aim to be a comprehensiveanalysis of all the barriers to condomaccess. However, where necessary, theanalysis has been complemented withcurrent best practices from the HIVprevention literature and additional inputfrom consultations with communitysector advocates.

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AIDS is the third largest killer in the world,but it is preventable. Yet every day 14,000people become infected with HIV, themajority through sex3. Many of thesecases could have been avoided4 if it werenot for restrictions and barriers on provenand effective prevention strategies, such

as condoms. It has been estimated thatas many as two-thirds of the new infec-tions expected to occur in the next 10years could be averted by the implemen-tation of a comprehensive range ofevidence-based prevention measures.5

HIV prevention and condoms

Methodology

1 United Nations General Assembly Special Session on HIV/AIDS. Declaration of Commitment on HIV/AIDS,adopted June 27, 2001

2 Cameroon, Canada, El Salvador, Honduras, Indonesia, Ireland, Jamaica, Morocco, Nepal, Nigeria, Peru, Romania, Serbia andMontenegro, and South Africa

3 UNAIDS,2006 Report on the global AIDS Epidemic (May 2006)4 Human Rights Watch,Access to Condoms and HIV/AIDS Information: A global health and human rights

concern (December 2004)5 UNAIDS,2006 Report on the global AIDS Epidemic (May 2006)

Peer educators during a World AIDS Day event, Sierra Leone Students Partnership Worldwide


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Male and female condoms6, if usedcorrectly and consistently, can reducethe risk of sexual transmission by 80-907

percent. In fact, condoms are the onlyproduct that can effectively protectagainst HIV and other sexually transmitted

infections (STIs)8

. Condoms are alsoessential to prevention efforts for peopleliving with HIV (PLHIV), providing protec-tion from STIs and re-infection, as well asprotecting their sexual partners.

However there is a serious gap in theavailability of condoms and relevant infor-mation on how to effectively use them.9

In the last few years, less than half of allpeople at risk of sexual transmission ofHIV had access to condoms and lessthan one quarter had access to basic

HIV/AIDS education.10 Researchers projectsupply gaps of billions of male condomsin sub-Saharan Africa alone.11The UnitedNations Population Fund (UNFPA) esti-mates that developing countries needaround 10 billion condoms per year, andmay need more than 18 billion by 2015.12

Condom shortages stem not only fromresource constraints, but also from gov-ernment policies that restrict condom

manufacture, procurement, distribution,and information on their use. Such poli-cies violate basic human rights, such asthe right to health, because states arerequired to refrain from limiting access tocontraceptives [] and from censoring,

withholding or intentionally misrepresentingpublic health information.13

As this suggests, constraints on supply isonly one aspect of the condom problem.Health development literature shows usthat the determinants of health includea broad range of interrelated factors,including biological, behavioral, cultural,political, legal and socio-economic14.

These factors will determine the levelsof individual risk and vulnerability to HIVinfection, including determining whether

a person uses a condom correctly andconsistently.

The frontline community research sup-ported by ICASO has provided evidenceof the influence of these determinantsand how they act as barriers to condomuse in the countries reviewed. For thepurposes of this paper, these barriers tocondom access have been grouped intofour categories. 3

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6 The male condom is placed over the glans and shaft of the penis, and is available in latex, lambskin, and polyurethane. Thefemale condom is a strong, soft, transparent sheath inserted into the vagina prior to sexual intercourse with a flexible ring ateach end, available in polyurethane and nitrile.

7 UNAIDS,2006 Report on the global AIDS Epidemic (May 2006)8 Population Action International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)9 GTZ, HIV/AIDS Prevention through Social Marketing of Condoms (undated)10 Human Rights Watch,Access to Condoms and HIV/AIDS Information: A global health and human rights

concern (December 2004)11 Estimates range from 1.9 to 13 billion. Shelton JD, et al., Condom gap in Africa: evidence from donor agencies and key inform-

ants. (2006); See also The Supply Initiative,Access to Condoms and Contraceptives Vital for the Prevention of HIV(2005).12 PopulationAction International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)13 Committee on Economic, Social and Cultural Rights (CESCR), The Right to the Highest Attainable Standard of Health: CESCR

General Comment 14 (22nd Sess., 2000) 04/07/200 E/C 12/2000/414 Canadian HIV/AIDS Legal Network, Healthy Public Policy. Assessing the impact of law and policy on human rights and HIV

prevention and care (2002).

Condom dress by Adriana Bertini, AIDS 2004 ICASO


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Socio-Cultural Barriers

While sex is a deeply personal experience,condom use during intercourse is oftentied to religious and cultural norms as wellas personal beliefs. Such norms helppeople define their own concepts of sex-ual morality or to internalize acceptablebehaviors. This section explores barriersto condom use that stem primarily frompersonal beliefs and knowledge, culture,social relations and religion.

Lack of womens empowermentand gender equality

The promotion of equality between menand women is essential to successful HIV

prevention, addressing both barriers toempowerment and sexual pleasure and

performance. Inside a heterosexualrelation, gender power relations aredirectly tied to a womans ability tonegotiate safer sex with her partner. Inmany cultures, women lack the power toinsist on condom use, both inside andoutside marriage.

Violence against women inside and out-side marriage, including rape and sexualassault, takes away womens controlover when, with whom, and how theyhave sex, and over whether or not they

can negotiate condom use during sexualintercourse. Furthermore, many womendo not feel comfortable talking about sexwith their partners or may stop using con-doms when involved in a long term rela-tionship as a sign of trust and faithfulness.

Barrier 1.1:

Condom Access Barriers

This document aims to provide an analysis of these barriers to condom useand access that were identified by community research, and where possi-ble provides recommendations for community sector advocacy.

1. Socio-Cultural Barriersnorms of culture, religion,and personal belief

2. Legal and Policy Barriersnational legislation and policies

3. Economic andFinancial Barrierscost and investment

4. Structural Barriersinfrastructure and humanresources


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Whether or not protection is usedandwhat kindis often decided by the man.Sometimes even the suggestion of usinga condom will be seen as an accusationof the partners infidelity, or an admissionof adultery on the part of the woman

herself. Such implications could provokeviolence and silence a woman fromspeaking up, even if her partners faithful-ness is suspect. In South Africa, forexample, fear of violence is reportedas a major barrier to condom use.15 InMorocco, the appearance of fidelity isso important that women can rarely insiston condom use even when her partner isHIV positive and she is not.16

Women also refuse to use condoms asmany relate condoms only with contra-

ception (and not with protection againstSTIs) and given that in many culturesbecoming pregnant is an indicator ofintimacy and commitment, women fearnegative repercussions from their partners.Married couples are among the least likelygroups to use condoms17, and marriageitself has become a prime risk factor forwomen. In Morocco, as elsewhere, themajority of HIV positive women have beeninfected by their husbands (65 percent).18

In some cultures where adultery or

polygamy is common19

unprotected sexwithin marriage is inherently risky. Earlymarriage (sometimes forced) and desireor social pressure to have children areother factors complicating condom use.

Gender norms around masculinity dictatethat men should be sexual risk takersand should be aggressive within sexualactivity. This of course affects the powerdynamics in the relationship, be this aheterosexual or homosexual relation. Menwho have sex with men (MSM), feminized

men and transgender people also experi-ence difficulties with condom negotiationand experience high levels of sexualviolence.20 Stigmatization and socialexclusion further disempowers thesepopulations, increasing their vulnerability

to HIV infection. For many, the sexualand gender roles they perform withinmale sexual practices lead to significantlevels of dominant sexual partners, sexualabuse, violence, rape, and harassment,often from an early age.21And of course,such forced sex is usually unsafe, andoften resulting in internal injuries, furtherincreasing their vulnerability to HIV infection.

Despite the effects of gender inequalityon condom use, very few of the countryreports supported by ICASO identified

HIV/AIDS programs specifically addressingwomens and sexual minorities rightsand gender equality.22This is despitegovernment commitments, includingthose made in the Declaration ofCommitment on HIV/AIDS in 2001.

By 2005, ensure development and

accelerated implementation of national

strategies for womens empowerment,

promotion and protection of womens full

enjoyment of all human rights and reduc-

tion of their vulnerability to HIV/AIDS

through the elimination of all forms of

discrimination, as well as all forms of

violence against women and girls[]

- (paragraph 61)

15 Mellors, S. Monitoring the Implementation of the UNGASS Declaration of Commitment: South AfricaCountry Report (2005) [hereinafter South Africa UNGASS Report]

16 Association de lutte contre le SIDA (ALCS), Monitoring the Implementation of the UNGASS Declaration of Commitment:Morocco Country Report (2005) [hereinafter Morocco UNGASS Report]

17 Population Action International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)18 Morocco UNGASS Report19 Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), Monitoring the Implementation of the UNGASS Declaration of

Commitment: Nigeria Country Report (2005) [hereinafter Nigeria UNGASS Report]20 NAZ Foundation International, The impact of social, legal and judicial impediments to sexual health promotion, and HIV and

AIDS related care and support for males who have sex with males in Bangladesh and India (2005)21 Ibid.22 Out of ICASOs 14 case studies, countries specifically reporting HIV/AIDS programs addressing gender are South Africa, El

Salvador, Jamaica, and Nigeria


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Sexual negotiation skills, taught as partof comprehensive programs exploringunderstanding of HIV, gender roles andpromoting mens involvement in sexualand reproductive health, can have signifi-cant effects on condom use. Both

women and men can be trained toimprove their communication, listeningand relationship skills and to respecteach others needs and desires for con-doms. In El Salvador, for example, work-shops have been held on gender andwomens empowerment, emphasizingwomens right to negotiate safe sex andmens and womens shared responsibilityin sexual decision making.23 In Jamaica,womens NGOs worked closely with theMinistry of Health in the development of

the National Strategic Plan and NationalHIV/AIDS Policy.24 Strategies adopted inthe policy include increased provisionand use of female condoms andstrengthening condom negotiation skills.

In Morocco, programs designed for

female sex workers focus on buildingtheir confidence, as a pre-requisite tosuccessful negotiation with clients forcondom use. In addition to distributingcondoms and lubricants, and informingsex workers about prevention methods,their self-esteem is improved throughwork with social workers. Developing apositive image of themselves is a prereq-uisite to engaging in safer sexual patterns.25

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Recommendationsfor community sector advocacy

Advocate for governments and donors to scale up, cost, and budget policy andprogrammatic actions promoting gender equality in their national responses toHIV/AIDS. This includes measures to support the empowerment of women andsexual minorities and to increase their ability to negotiate condom use.

Advocate for governments to adopt legislation and/or establish effective enforcementmechanisms that support gender equality (e.g. inheritance rights).

Advocate for governments to abolish laws and policies that criminalize behaviours ofsexual minorities, such as MSM and transgender.

23 Asociacin Atlacatl Vivo Positivo, Monitoring the Implementation of the UNGASS Declaration of Commitment: El SalvadorCountry Report (2006) [hereinafter El Salvador UNGASS Report]

24 Jamaican AIDS Support (JAS) Monitoring the Implementation of the UNGASS Declaration of Commitment: Jamaica CountryReport (2005) [hereinafter Jamaica UNGASS Report]

25 Morocco UNGASS Report26 Human Rights Watch,Access to condoms and HIV/AIDS information: A Global health and human rights

concern (2004)

Religion and morality

An overly rigid, or moralistic, view of sex-ual activity and the belief that condompromotion encourages sex is a strongdeterrent to condom use. Cultural andreligious notions of morality equatingcondoms with promiscuity limits both the

availability of condoms and personalease of comfort in using them. Althoughofficial Roman Catholic teaching is silenton the use of condoms to protect againstHIV infection,26 it opposes the use of con-doms for birth control, and many within

the hierarchy of the Church have inter-preted this as ban on condom use forany purpose.

Barrier 1.2:


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27 UNAIDS, Practical Guidelines for Intensifying HIV prevention (2006)28 International HIV/AIDS Alliance and Reproductive Health Matters, Emerging Issues: Condom policy and

programming, (2006)29 Nigeria UNGASS Report30 El Salvador UNGASS Report31 Morocco UNGASS Report32 PITA Foundation, Monitoring the Implementation of the UNGASS Declaration of Commitment: Indonesia Country Report (2006)

[hereinafter Indonesia UNGASS Report]33 Human Rights Watch,Access to Condoms and HIV/AIDS Information: A global health and human rights

concern (December 2004)

Many faith-based organisations, and gov-ernments influenced by religious ideology,have adopted the ABC approach toprevention: Abstinence, Be faithful; anduse Condoms.27 Often their emphasis isonly on abstinence and be faithful, posi-tioning condom use for those unable to

meet moral standards. This ABCapproach fails to deal with the needfor a more comprehensive approachto prevention including, for example,empowerment, sexuality and life skillseducation. This particular approach ismost problematic because it increasesthe stigma and discrimination of thoseusing condoms.28

In Nigeria, many people are reluctant tobuy condoms for fear of seeming sexuallyloose.29 In El Salvador, pharmacists

have refused to sell condoms due toreligious beliefs, which also influencedhealth care workers willingness to

promote condom use.30 In some coun-tries, condoms are primarily associatedwith marginalized groups such as sexworkers: until recently in Morocco, thepossession of condoms was seen asproof of soliciting sex.31

In Indonesia, prevention efforts are heavilycriticized by some religious organizationsclaiming that such messages includingcondom promotion encourages sex.32

Not only do some religious ideologiesmake it difficult to advocate for safer sex,but some religious leaders have sentinaccurate messages about condomeffectiveness.33The high status of religiousleaders in many societies puts them inposition of influence that needs to beharnessed for HIV prevention andcondom promotion.

Workshop on HIV prevention and condom use, Yukpa indigenous community, Venezuela AMA VIDA 2007


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Fellow South Africans, I am Archbishop Desmond Tutu.

Our great nation faces a terrible challenge with HIV and AIDS

spreading so fast. We in the church believe that sex should

only take place within marriage. However, for those of you who

do practice sex outside of marriage, I encourage you to take the

right precautions and practice safer sex. Please use condoms.34

- The Most Revd Dr. Desmond Tutu

Primate of the Church of the Province of Southern Africa

In Morocco, a project with the Ministry ofIslamic Affairs aims to transform Imamsinto major actors in the fight against AIDS.35

This includes a training/mobilizing plan for

30,000 Moroccan Imams. This initiativecame out of the Regional Cairo Colloquiumfor Religious Leaders in Response toHIV/AIDS, which involved 80 top Muslimand Christian Arab religious leaders.

These leaders produced a progressive and somewhat revolutionary declaration.36

In Nigeria, a new curriculum for compre-hensive sex education has been intro-duced, developed in consultation withreligious and community leaders.37 While

the previous nationally-approved curriculumfor HIV prevention included condom infor-mation as part of comprehensive educationstrategies, this curriculum was rarely taught.

In fact, local government bowing toreligious pressure blocked itsimplementation.38

In Mozambique, a project involving localCatholic priests and nuns promoted safersex among married couples. Couplecounseling focused on pleasure facilitatedbetter communication between marriedcouples and encouraged them to talkmore openly about their likes and dislikesabout sex.39

34 UNAIDS and PSI, Social marketing: Expanding access to essential products and services to preventHIV/AIDS and to limit the impact of the epidemic (2000).

35 Morocco UNGASS Report36 Network of Arab Religious Leaders Responding to AIDS (CHAHAMA) The Cairo Declaration of Religious Leaders in the Arab

States in Response to the HIV/AIDS Epidemic (2004).37 Nigeria UNGASS Report38 Human Rights Watch,Access to condoms and HIV/AIDS information: A Global health and human rights

concern (2004).39 Anne Philpott, et al., Pleasure and Prevention: When Good Sex Is Safer sex, Reproductive Health Matters, Vol 14, No.28

(Nov 2006).


Advocate for religious leaders to promote a more comprehensive preventionapproach that includes the right of people to access complete, accurate, evidence-based information about HIV prevention, including sexuality and life skills educationand condom use.


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Personal beliefs and pleasure

Lack of understanding about HIVincluding misperceptions of risk

impedes condom promotion efforts.Research has shown that condom useis lowest amongst married partners, whotend to trust their regular partner, andyoung people who may feel invinciblefrom disease.40The rates of condom useare even lower among women and menin the general population who have notbeen exposed to condom promotion.

This data also shows that men are gen-erally less willing to use condoms withtheir long-term partners than they are

with casual partners or paid sex partners.41

In most cultures, a real man is definedby his sexual conquests. Some menconsider sex to be their right, and pleasurean obvious by-product of sexual relations.

Across the world, however, concernexistsprimarily among menaboutwhether condoms reduce the sensationand enjoyment of sex, and affect sexualperformance. Men in multiple contextscompare wearing a condom to taking abath with your boots on or smelling a

rose through a gas mask.42 Social pres-sures on men to enjoy sex or prove theirmasculinity may impede condom use,even in high-risk situations. In Nigeria, for

example, low levels of condom useamong sex workers stems from a lack ofacceptance by male clients,43 based ontheir personal beliefs.

Pursuit of pleasure is an important reasonthat people have sex. Growing evidence

exists that associating pleasure with maleand female condoms increases their use.44

Conversely, emphasis on disease and thenegative potential outcomes of sex maylimit the effectiveness of prevention andcondom promotion.45 Focusing on positiveapproaches and eroticizing condom useis therefore a means for overcomingconcerns of pleasure and performance.

Social marketing efforts can capitalize onthese opportunities. Packaging condoms

along with lubricant to diminish frictionand discomfort, and promoting condomsalong with other kinds of erotic acces-sories are only a few of the means thathave been used to boost condom sales.In Mongolia, for example, the Lady Trustbrand of female condoms, explicitlymarketed to increase male and femalepleasure, experienced high sales growth.46

Another strategy used to promote condomuse is using entertainment while educating.Examples include radio and TV shows,

street and music festivals,47

art andperformance.48 Most of these are targetedto youth and have messages on HIVprevention, particularly condom use.

Barrier 1.3:

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40 Population Action International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)41 Global Campaign for Microbicides,Addressing Questions and Common Misperceptions about Microbicide Clinical Trials (Fact

Sheet #18) (undated)42 International HIV/AIDS Alliance, Reproductive Health Matters, Emerging Issues: Condom Policy and Programming (2006)43 Nigeria UNGASS Report44 Anne Philpott, Promoting protection and pleasure: amplifying the effectiveness of barriers against sexually transmitted infections

and pregnancy, 368 The Lancet45 Ibid46 Ibid47 For example, 48 Fest, an initiative of the Staying Alive Foundation (http://eu.staying-alive.org/48fest/index.html).48 The Condom Project www.thecondomproject.org


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Legal and Policy Barriers

Countries and donors should remove laws and conditionalities that restrict or criminalizethe use or promotion of HIV commodities and services including [] male and female

condoms []49

Community sector advocates, 2006

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Advocate for governments and other stakeholders to implement programs toeducate people on condom use in a friendly, non-threatening way. These programs

should focus on positive incentives to condom use, particularly on how condomscan enhance the sexual experience and increase pleasure.

Advocate for governments to develop and implement AIDS plans that strengthensocial marketing and the community level provision of condoms and condomcounseling, including support for peer education.

Culture, religion and personal beliefsabout condom use are inextricably linkedto country level policies. Such policiesreflect traditions and norms, as well asinfluence them. This section exploresbarriers to condom use that stem fromnational policies and laws. These includepolicies and legislation that ban or restrictcondom distribution, that discriminateagainst those most vulnerable to HIV infec-tion, and that criminalize certain behaviors.

Legislation and policy oncondom availability

In some countries, restrictive measures oncondoms are institutionalized as officialgovernment policy. In the Philippines, forexample, the government refused to supply

condoms to the public sector with nationalfunds, condoms were prohibited frompublic health clinics, and police activelyinterfered with condom promotion.50

In other countries, government is divided

on AIDS policies with one sector under-mining the work of the other. In Morocco,for example, staff and beneficiaries workingunder programs created and supported bythe Ministry of Health have been arrestedfor condom promotion.51 Even socialworkers working with at-risk populationshave been arrested and accused ofincitement to vice.52 In Nepal, MSM andsex workers the highest risk groups have been arrested for carrying condoms.53

In Jamaica, the Ministry of Health has

developed specific prevention messagesfor young people, and women, yet nothingtargeting MSM or sex workers.54

Barrier 2.1:

49 ICASO,A Call for Political Leadership: Community Sector recommendations for the UN Political Declaration on HIV/AIDS (2006)50 Human Rights Watch, Unprotected: sex, condoms and the human right to health (2004)51 Morocco UNGASS Report52 Morocco UNGASS Report53 Blue Diamond Society, Monitoring the Implementation of the UNGASS Declaration of Commitment: Nepal Country Report

(2006) [hereinafter Nepal UNGASS Report]54 Jamaica UNGASS Report


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Even in Canada, a country with universalhealth care, high standards of living, andan awareness of human rights, some ofthe most vulnerable populations youth,

Aborigines, small rural communities,refugees, and trafficked women have

limited access to male and female con-doms.55 In Romania, while the governmenthas carried out campaigns for urbanyouth, out of school youngsters and ruralyouth are virtually excluded from condompromotion activities.56 Despite high levelsof adolescent sexual activity in Jamaica,health workers cannot freely offer preven-tion options to youth. Instead, they mustbalance the best interests of the childwith the parents right of consent.57

Prisoners remain another excluded group,often without regular access to condoms.Reports from Honduras to Romaniacommented on the lack of condomdistribution within prisons, and the needfor better prevention efforts within jails.58

In Canada, condoms and lubricant arenot available in some provincial prisons,and in many provincial prisons they arenot easily or discreetly available.59 InMorocco, prisoners can only get condomscovertly through their family or wardens,and it is common to hide condoms inbasket meals brought by visiting families.60

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Advocate for governments to remove laws and conditionalities that restrict and/orcriminalize the promotion or use of condoms, including for those most vulnerable toor at risk of HIV infection and in certain settings.

55 AIDS Calgary Awareness Association, Monitoring the Implementation of the UNGASS Declaration of Commitment: CanadaCountry Report (2005) [hereinafter Canada UNGASS Report]

56 ARAS, Monitoring the Implementation of the UNGASS Declaration of Commitment: Romania Country Report (2005) [hereinafterRomania UNGASS Report]

57 Jamaica UNGASS Report58 ICASO, Community Monitoring and evaluation of the implementation of the UNGASS Declaration of Commitment on HIV/AIDS

(2006)59 Canada UNGASS Report60 Morocco UNGASS Report

Khote/transgender sex workers at a trucking depot The Condom Project


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Marginalization, discriminationand criminalization of vulnerablepopulations

In 2001, through the Declaration ofCommitment on HIV/AIDS61, governmentspledged to implement measures to elim-inate all forms of discrimination againstPLHIV and members of groups mostvulnerable to HIV. Other internationaltreaties, resolutions, and declarations,and many national legal systems are setup to protect in theory the fundamentalright to be free from discrimination.

Barrier 2.2:

By 2003, enact, strengthen or enforce, as appropriate, legislation,regulations and other measures to eliminate all forms of discrimi-

nation against and to ensure the full enjoyment of all human

rights and fundamental freedoms by people living with HIV/AIDS

and members of vulnerable groups, in particular to ensure their

access to [], health care, social and health services, prevention,

[] information and legal protections [] and develop strategies

to combat stigma and social exclusion connected with the epidemic

The Declaration of Commitment on HIV/AIDS, 2001 (paragraph 58)

However, there remains a huge gapbetween what exists on paper on anti-discrimination policy and law and whathappens in reality. Reports abound ofdiscrimination in service provision, espe-cially against the most marginalized,including sex workers, men who have sexwith men, and injecting drug users (IDU)

who have a higher risk and vulnerabilityto HIV infection, as well as against peopleliving with HIV.62 Lack of protectionsagainst discrimination by some health andHIV prevention workers poses one of thebiggest barriers to the provision andaccess to services and commodities(including condoms) for these populations.

Rodrigo and Carlos, gay rights and HIV activists,LGBTT Pride March, Mexico (2005) Ave deMxico

61 United Nations General Assembly Special Session on HIV/AIDS , Declaration of Commitment on HIV/AIDS, adopted June 27,2001

62 UNAIDS,2006 Report on the global AIDS Epidemic (May 2006)


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Making things worse is the fact thatmorality and social norms dictate thatcertain behaviors or professions need tobe criminalized, such as drug use, sexwork and same sex sexual relations,particularly between men. For example,

while health and social welfare ministersinclude in their programs to work withmarginalized and vulnerable groups, otherministries and levels of government (suchas judicial and internal affairs) promotelaws that criminalize these behaviors.

In countries where sex work is illegal sex work remains illegal in most of the 14countries that were analyzed in the ICASO

study63 sex workers have difficultyaccessing health services, obtaining asufficient number of condoms from clinics,or insisting on condom use. Street-basedsex workers in particular have little timeto negotiate condom use with clients

before driving off with them because theyfear arrest.64 In many countries arrestcan result in violence and rape. In theseenvironments, police or military personnelshould not be given any form of controlover sex workers, or other vulnerablegroups in prevention and condompromotion programmes[see 100% condom use programs box].

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100% Condom Use Programs violations of human rights

One HIV prevention approach that is highly criticized by sex workers for its humanrights violations is the 100% Condom Use Program (100% CUP). It is designed as acollaborative program between local authorities and the sex entertainment establish-ments that aims to reduce sexual transmission of HIV by assuring condom useamong sex workers and their clients.65 However, the 100% CUP was developedwithout consultation with sex workers and their advocates.66

The 100% CUP implemented in Thailand and Cambodia include mechanisms ofcontrol over sex workers by armed personnel, including the police and military. Sexworkers around the world regularly cite these groups as the most frequent violators

of their rights, including forced sex that usually takes place without a condom. Whilereductions in HIV infection are being identified in the short term, there are concernsby sex worker networks that this approach continues to have negative repercussionsfor sex workers, increasing their risk to violence and abuse, and therefore to HIVinfection.67

This program assumes that sex workers have the ability, or even the power, to nego-tiate condom use, although there have been documented cases of sex workersbeing beaten because of their position of no condom no sex.68This program failsto address likely human rights violations stemming from the role of the police and themilitary in enforcing the program. It fails to address and protect sex workers who aredismissed from the establishments (either because they have an STI, including HIV,

or because they did not comply with the 100% CUP). These sex workers often endup in more vulnerable work situations and at higher risk of HIV infection. 69

63 ICASO, Community Monitoring and evaluation of the implementation of the UNGASS Declaration of Commitment on HIV/AIDS(2006)

64 Business Day, Johannesburg. Old Law a Curse on South Africas Sex workers, March 3, 200665 Wiwat R., The 100% condom use programme in Asia, Reproductive Health Matters, Vol 14, No.28 (Nov 2006).66 Loff, B., Over C., and Longo, P., Can health programmes lead to mistreatment of sex workers? 361 The Lancet 1982 (2003)67 Ibid68 Business Day, Johannesburg. Old Law a Curse on South Africas Sex workers, March 3, 200669 Ibid


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More efforts are needed to empower sexworkers and other marginalized groups to negotiate condom use and performsafer sex. This includes training to simulaterisky acts, to promote non-penetrativealternatives, and to eroticize condoms.

Other methods of condom promotion

without violating human rights ordecreasing the earnings of sex workers(and thereby forcing sex workers to pursuemore clients) are recommended for every-one, including clients of sex workers,managers and go-betweens, as well as

sex workers themselves.70


Advocate for governments to review, implement, and adopt additional legislation andpolicies and establish effective enforcement mechanisms to support gender equalityand non-discrimination of those most at risk and vulnerable. This includes people livingwith HIV, women, youth, men who have sex with men, sex workers, injection drugusers, transgender, prisoners and migrants71.

Advocate for governments to know their epidemic to ensure that they designprograms that will be most effective,72 including providing condoms and informationabout their use to those most at risk of HIV infection.

Advocate for governments to remove laws that criminalize certain behaviors or work,such as same sex relations, drug use and sex work.

Advocate for governments to ensure that legal and policy protections are extendedto outreach workers and advocates, to prevent them from being detained and/orharassed for distributing condoms or providing prevention information.

Advocate for governments and donors to provide financial support to encourage theinvolvement of those most at risk and vulnerable in the design of prevention strategies,outreach programs and condom and lubricant promotion and distribution.

Economic and Financial

Barriers

Condom use is one of the least expensive,most cost-effective methods for preventingHIV. In addition, HIV infections averted nowsave millions of dollars spent later ontreatment, lost productivity, and lives. Yet

cost continues to be a major barrier to

accessing condoms. Many governmentshave consistently failed to keep condomprices affordable through the impositionof taxes and a lack of investment in socialmarketing. This lack of support has alsobeen affected by the financial influence ofsome international donors imposing ideo-logically motivated restrictions on condompromotion.

70 Deanna Kerrigan, et al., Environmental-Structural Interventions to Reduce HIV/STI Risk Among Female Sex Workers in theDominican Republic, 96 American Journal of Public Health (2006)

71 ICASO,A Call for Political Leadership: Community Sector Recommendations for the UN Political Declaration on HIV/AIDS(2006)

72 UNAIDS, Practical Guidelines for Intensifying HIV prevention, (2006)


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Taxes and tariffs on imported or evenlocally manufactured condoms or on the

raw materials needed for their productioncause the price of condoms to rise insome countries. In Ireland, despite currenthigh rates of sexually transmitted infections,condoms are designated as a luxury good,rather than an essential item. They aretherefore subject to a 21 percent value-added tax, one of the highest in Europe,that increases their price, and that thenconstitutes an impediment to their use,particularly among low-income popula-tions.73

In Brazil in the early 1990s, high importtariffs on latex (the raw material used forcondoms) and multiple taxes at everyretail level made condoms extremely

expensive, resulting in low per capitacondom use. In recognizing this barrier,a partnership developed between inter-national organisations, manufacturers,importers, the private sector, trade unions,the media, and the public sector on acampaign to eliminate condom taxes and

make them more affordable. Their advo-cacy resulted in the Brazilian governmenteliminating import tax on imported brandsand significantly lowering the price ofthose locally produced. Condom salesrose from 53 million in 1995 to 300million in 1998.74

Of critical importance is the need toinvest in scaling up the social marketingof condoms, making them available andaffordable to low-income people.75Thisis particularly true for female condoms,where limited awareness and demand iskeeping costs high.[see the female condom box]

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Taxes, economic restrictions,and cost

Barrier 3.1:

73 Gay HIV Strategies - Gay and Lesbian Equality Network (GLEN) and Health and Development Networks, Monitoring theImplementation of the UNGASS Declaration of Commitment: Ireland Country Report (2006) [hereinafter Ireland UNGASSReport]

74 FHI, Involving the Private Sector in HIV Prevention in Brazil(undated)75 UNAIDS and PSI, Social marketing: Expanding access to essential products and services to prevent

HIV/AIDS and to limit the impact of the epidemic (2000).

Condom dress by Adriana Bertini, AIDS 2004 ICASO


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Governments from developing countrieshave consistently failed to adequately pri-oritize condom purchase in their budg-ets.83 Consequently, in much of thedeveloping world condom availability hasbeen overly dependent upon a smallgroup of bilateral and multilateral donorssuch as the United States, Germany,the United Kingdom and UNFPA, as wellas international organizations such as

PSI [see the annual average number ofcondoms chart].

In 2004 donor governments providedfewer than four male condoms per man

per year in the developing world.84

This has resulted in a significant under-supply problem. In the year 2000,donors provided support for fewer thanone billion condoms to thedeveloping world, only one-eighth ofwhat was needed.85 In 2002 that figurerose to 3.6 billion, or one-third of esti-mated condom need. However thisincrease was only due to one-time con-tributions from Canada, the Netherlandsand the United Kingdom.86 If donor gov-ernments give the same percentage in2015 as they did in 2002, there will stillbe a 12.6 billion condom gap.87


Advocate for governments to eliminate tariffs and taxes on male and femalecondoms and other prevention commodities that may increase cost and decrease

access to condoms. Advocate for manufacturers to reduce the price of female condoms, and for

governments and donors to increase funding for the marketing and distributionof female condoms.

Advocate for increased investment in the development of prevention methodsthat women can control, including microbicides82.

Influence of donors oncondom access

Barrier 3.2:

82 Microbicides are vaginal products being developed to reduce the transmission of HIV during sexual intercourse. Microbicidescould take the form of a gel, cream, film, suppository or sponge, or be contained in a vaginal ring that releases the active ingre-dient gradually. See the International Partnership for Microbicides: www.ipm-microbicides.org.

83 Interact Worldwide, Condom shortage: counting the cost in lives (2006).84 Ibid85 The Supply Initiative,Access to Condoms and Contraceptives Vital For the Prevention of HIV(2005).86 Population Action International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)87 The Supply Initiative,Access to Condoms and Contraceptives Vital For the Prevention of HIV(2005).


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88 Committee on Economic, Social and Cultural Rights (CESCR), The Right to the Highest Attainable Standard of Health: CESCRGeneral Comment 14 (22nd Sess., 2000) 04/07/200 E/C 12/2000/4

89 Center for Health and Gender Equity (CHANGE), New Analysis Shows U.S. Global AIDS Policy Further Undermining HIVPrevention in Sub-Saharan Africa (2005).

Added to this lack of funding, thereliance on a few donors leaves condomaccess and availability open to influenceby individual donor policies and agendas.

This includes the imposition of ideologically-motivated restrictions on condom promotionover evidence-based preventionapproaches, violating recognized humanrights.88 For example, while the United

States has been the single largest sourceof condoms for the developing world,recent changes in policies, through thePresidents Emergency Program for AIDSRelief (PEPFAR), has seen budget allo-cations emphasize abstinence and fidelityover condom use.

PEPFAR stipulates that one-third ofprevention funding must be spent onabstinence before marriage interventions.It advocates condom promotion only forso called high risk groups such as sexworkers, truck drivers and HIV-discordantcouples.89This approach does not suffi-

ciently recognize marriage as a risk factoror include married couples as a specialfocus of its programming interventions. Bydesignating certain groups as high risk, itnot only promotes stigma of condom use,but implies that other groups are somehowimmune to HIV and do not need accessto condoms. Furthermore, its focus onHIV-discordant couples is futile in countries

where the majority of people are unawareof their HIV status.

As the largest global health grant everannounced by any donor government, theUS$15 billion HIV/AIDS program providesa huge influx of new resources to countrieswith significant epidemics, primarily thosein sub-Saharan Africa. However, with thecurrent reliance on international funding ofcondoms, PEPFAR is strongly affectingpolicies and programming prioritiesaround condom-based prevention.

(Source: PAI, Condom count 2006 Data Update)


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Some civil society actors and governmentshave responded to these budgetrestrictions by changing the direction oftheir work to abstinence and faithfulnessover condom promotion or more compre-hensive prevention approaches. InNigeria, for example, it is evident that

there has been an increasing shift withinthe prevention budget of the projectssupported by PEPFAR to favor absti-nence and faithfulness approaches (ashift from 40 percent of the allocation ofthe 2004 budget to 70 percent in 2005).90


Advocate for governments to allocate specific lines in national budgets for thepurchase of condoms and other health supplies, establishing tracking mechanismsto monitor spending in order to predict and avoid condom shortfalls.

Advocate for donors to increase their financing of condom purchases, and call onalternative donors to provide funding where existing donors impose ideologically-based restrictions on condom promotion and comprehensive HIV prevention

programming. Advocate for all donors to remove conditionalities that restrict the use or promotion

of condoms and related services.

Structural Barriers

HIV/AIDS infrastructure can be definedas everything it takes to get prevention, treat-ment, care and support to the people who

need it, including human resources; com-modities and supplies; and health, education,and other systems necessary to ensure qual-ity and consistent services.

In relation to condom access, there are somesystemic infrastructural barriers that havebeen identified by community groups. Theseinclude lack of quality sex education, compli-cated condom supply, procurement, anddistribution systems, and limited integrationbetween sexual and reproductive health andHIV/AIDS services.

Availability and quality ofsexuality education

Taught properly, sex, health, and life skillseducation can empower boys and girls tomake healthy choices about sexual behaviors,including protecting themselves from HIV.

Young people, in particular, may be ignorantabout how HIV is transmitted or underestimatethe consequences of acquiring it. In Serbia,29 percent of young people aged 18-28 thinkHIV can be transmitted by kissing an HIV posi-tive person, while 28 percent think they canbe infected through mosquito bites.91

In Canada, approximately 50 percent of

students aged 14-15 do not know that thereis no cure for AIDS.92

Barrier 4.1:

90 Center for Health and Gender Equity (CHANGE), Risk and Reality: U.S. Funding of HIV Prevention Programs in Nigeria (2006).91 Yugoslav Youth Information center (YYIC), Monitoring the Implementation of the UNGASS Declaration of Commitment: Serbia

and Montenegro Country Report (2005) [hereinafter Serbia and Montenegro UNGASS Report]92 Council of Ministers of Education, Canada, Canadian Youth, Sexual Health and HIV/AIDS Study: Factors influencing knowledge,

attitudes and behaviors (2002).

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In Morocco, while most young people areaware of the existence of HIV/AIDS, theirprevention knowledge is extremely limited,even in urban areas. Studies amongcollege students show that less thantwo-thirds of men and only one-third of

women could identify condoms as ameans of protection. Knowledge levelsamongst uneducated and less-educatedyoung people in Morocco are dramaticallylower.93A recent international review94

found that girls who had completedsecondary education had a lower riskof HIV infection and practiced safer sexthan girls who had only finished primaryeducation.

By 2005, ensure that at least 90% and by 2010 at least 95% ofyoung men and women aged 15 to 24 have access to the infor-

mation, education, including peer education and youth-specific HIV

education, and services necessary to develop the life skills

required to reduce their vulnerability to HIV infection []

The Declaration of Commitment on HIV/AIDS, 2001.

93 Morocco UNGASS Report94 Hargreaves J., et al. (Action Aid International), Girl power: The impact of girls education on HIV and sexual behaviour. (2005)95 Rivers, K, Aggelton, P.Adolescent Sexuality, Gender and the HIV Epidermic (undated)96 Policy Project, et al., Coverage of selected services for HIV/AIDS prevention, care and support in low and middle income

countries in 2003 (2004)

Condom outreach work with youth, Ethiopia The Condom Project

Schools have become the main venue forproviding sex education, either integrated

into existing curricula or as a stand-alonesubject. School-based education on con-doms and HIV prevention is especiallyimportant because of the changing rolesof family and community in providingguidance about sex. For example,whereas the provision of informationabout sex in Africa used to be formalizedas part of initiation into adulthood, thisinformation is often now obtained fromthe media, school, or friends.95

However, in a recent study the PolicyProject estimated that the percentage of

secondary students receiving HIV/AIDSeducation in 69 countries (middle and lowincome) was less than 50 percent, eventhough almost 90 percent of the countrieshad included HIV/AIDS as part of secondaryschool curriculum.96

In some countries, there is no sex educa-tion at all, leaving children without thebenefit of information or vulnerable to mis-information about HIV. In other countries


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Advocate for governments to review the content of HIV-related curricula in schoolsand to implement comprehensive, accurate, evidence-based sexuality and reproductivehealth education, including information about condom use.

Advocate for governments to scale up efforts to reach those who are not part of theschool system, such as street kids or young adults who have finished their education.

97 Jamaica UNGASS Report98 Human Rights Watch,Access to condoms and HIV/AIDS information: A Global Health and human rights

concern (2004)99 Ibid100 CHANGE, Barrier Methods For HIV Prevention: Science, Evidence, and Politics in Global AIDS Prevention (undated)

such as Jamaica, information aboutcondoms may be left out of health educa-tion programs, in response to complaintsfrom parents or teachers afraid thatteaching about condoms itself promotessex.97 In India, for example, even in schools

where HIV/AIDS information is offered,details of transmission and condom usemay be omitted. Frequently, students arenot taught that they can get HIV throughsexual contact, or how to protect them-selves. Rather, the focus of such programsis on parenting, disease, and abstinence.98

Condom promotion in Nigerian schools islimited. While the national curriculum forHIV prevention education includes com-prehensive education and condom pro-motion messages, few state govern-ments have adopted and implemented it

in their schools.99

In contrast, Senegal,with its active HIV prevention educationcampaigns, including in-school sexualityeducation, maintained one of the lowestHIV prevalence rates in Africa.100

I use, and you? Campaign to promote condom use

among young gay men, Cuernavaca, Mexico Edgar Marquez Ortega (2006)


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Advocate for governments to improve and streamline condom procurement, purchasing

and distribution systems, for both family planning and HIV prevention services. Advocate for programmes to make condoms and information about them available in

more diverse places where those most at risk and vulnerable to HIV infection meet.

Supply and distribution systems

Condoms move through multiple supplysystems before they get to their final pointof sale or distribution. From manufacturers

to quality control, and from donors togovernments and the private sector, con-doms are subject to particular standardsof storage, logistics, and purchasing. Pro-curement policies of both donors anddeveloping country governments are ofteninconsistent and uncoordinated, resulting inwasted resources and inadequate supplies.101

Limited distribution systems, particularly inrural areas, constrain their availability andcomplicate access. In Ireland, for example,prevention information and commoditiesare primarily available in the urban areasand on the East Coast, while rural areasare poorly served.102 In Romania, widedifferences in condom availability exist by

residence, type of outlet and region of thecountry. Condoms are widely available inpharmacies and supermarkets (over 80percent) and service stations (over 60percent), but are only available in about40 percent of hotels and only 25 percent

of all retail outlets sell them in rural areas.103

Diversifying points of distribution can helpaddress issues around condom supplyand access, for example, providing freecondoms to clients at HIV-treatment andvoluntary counseling and testing centers.In addition to providing condoms in healthsettings and making them available insupermarkets and pharmacies, condomsshould be distributed to non-traditionaloutlets such as hotels, clubs, taxi stands,and by peer educators.104 In South Africa,

community groups recommended supply-ing condoms in spaza shops, informalbusinesses in township and poorer areas.105

Barrier 4.2:

101 Population Action International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)102 Ireland UNGASS Report103 Romania UNGASS Report104 Population Action International, Condoms count. Meeting the need in the era of HIV/AIDS. The PAI report card(2002)105 South Africa UNGASS Report


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Advocate for AIDS service providers to offer sexual and reproductive health services,such as testing and treatment for STI and counseling about safe pregnancy forPLHIV.

Advocate for sexual and reproductive health service providers to offer AIDS-relatedservices to their clients, including voluntary HIV counseling and testing, referrals, andcondom counseling and supplies.

Integration of sexual andreproductive health andHIV/AIDS services

Commitments have been made by theinternational community to intensify link-ages between sexual and reproductivehealth (SRH) and HIV/AIDS at the policyand program level.106 Stronger linkagesshould lead to important public healthbenefits, such as improved access anduptake of services, particularly for PLHIV,with SRH services specially tailored totheir needs, and better support for theuse of condoms as dual protectionagainst unwanted pregnancy and sexually

transmitted infections, including HIV.Most HIV infections worldwide are sexuallytransmitted or are associated with preg-nancy, childbirth or breastfeeding.107

Furthermore, the presence of sexuallytransmitted infections increases the proba-bility of contracting HIV. Many of the sameresponses used to address sexual andreproductive health, including condom use,can also be used to address HIV and AIDS.

Better integration of SRH and HIV/AIDSservices can help cut costs, increaseeffectiveness, and better serve clientneeds. Weak linkages between agenciesprocuring condoms for HIV preventionand those for family planning increase

the inefficiency of procurement systems.On an operational level, better integrationcan include coordination to involve SRHservices such as family planning or STIdiagnosis as part of VCT services, and toensure male and female condoms areavailable at all points of service. Pre- andpost-test counseling sessions availableas part of VCT can support effectivecondom use, and may reach people whomight not use traditional family planningservices, such as men and adolescents.

VCT services can also make greater useof condom social marketing and freecondom distribution as a way to promotedemand for their services. Workingtogether and pooling human resourcesmay also be a way to address theshortage of trained counselors promotingcondom use.

Barrier 4.3:

106 Examples of these include the UNAIDS policy position paper on Intensifying HIV Prevention (2006) and the Glion Call to Actionon Family Planning and HIV/AIDS in women and children (2004).

107 International Planned Parenthood Federation (IPPF), et al., Sexual and Reproductive Health and HIV/AIDS: A framework forPriority Linkages, (2005)


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Copyright 2007 by the International Council of AIDS Service Organizations (ICASO).

International Secretariat65 Wellesley Street E., Suite 403

Toronto, Ontario, Canada M4Y 1G7t: +1 416 921 0018 f: +1 416 921 [email protected] www.icaso.org

ICASO International Council ofAIDS Service Organizations

Many of the community advocacyrecommendations within this Advocacy

Briefing are based on existing calls tonational governments and the interna-tional community from community repre-sentatives. As such this document formspart of a broader community mobilisationto ensure that governments, donors andother stakeholders address the funda-mental barriers to condom access.

Working together, the community sectorneeds to ensure that those most at riskand vulnerable to HIV are able to protectthemselves, and that governments deliveron their existing commitments topreventing HIV.

ICASO works with community organisa-tions around the world to ensure that

these and other community calls foraction are delivered upon. If you wishto work with ICASO on condom accessadvocacy or have suggestions for otherrecommendations and action, pleasecontact us directly.

Next Steps

Documents

Barriers to Condom Access: setting an advocacy agenda - ICASO Advocacy Briefing