Introducing the female condom into a male condom programme resulted in a small, but significant, increase in the proportion of sex workers reporting 100% condom use with all partners. This result replicates what has been found in other sex workers,12,13
and high risk populations14,15,16
—namely, that complementing male condom promotion programmes with the female condom increases reported condom use. However, these increases have not always been accompanied by decreases in sexually transmitted infections.13,16
This discrepancy usually gives rise to a discussion on the validity of self reported condom use.17
Our analyses of the prostate specific antigen (PSA) samples at baseline and the final follow up indicated that although there was under‐reporting of unprotected sex, these levels remained constant during the study, implying that the changes that we witnessed in consistent condom use were real.10
While over‐reporting of protected sex may not have influenced the consistent condom use outcome, it is possible that contact with the research staff could have been responsible for some of the other positive effects of the intervention that we observed. For example, the reported number of casual and regular clients decreased by 50%, and 30%, respectively, during the study, although this was not a specific objective of the intervention. Similarly, the reported total number of coital acts and the number of unprotected acts with all partners decreased over time by 25% and 20%, respectively. Discussions with the sex workers after the study revealed that the participants may have been positively influenced by their numerous contacts with study personnel, both because the process of counting sex acts raised their awareness of how much (sometimes unpaid) sex they were having, and because study personnel also provided information on sexual health after the interviews were completed, according to the study protocol. This fact, combined with the fact that most of the downward trends started before the introduction of the female condom, raises questions about the degree to which the female condom was instrumental in the decline of some of these risky behaviours. However, it cannot be denied that a sharp drop in the number of unprotected coital acts, and a sharp increase in consistent condom use, was observed directly after the introduction of the female condom, indicating some effectiveness.
Other limitations to this study were the small study size and the pre‐post intervention design. The small study size was a result of budgetary constraints in a study where participants come from a highly mobile population, and thus need to be followed up every 2 months in order for them not to go missing. It is because of this intensive follow up carried out by the research assistants that we were able to retain 92% of the participants over the 12 month study period.
In our study, about 30% of male condom use before female condom introduction was replaced by female condoms despite messages emphasising its use only when using a male condom was not possible. Such “condom migration” does not seem to lead to more sexually transmitted infections,18
but it has cost implications. The cost of the female condoms alone—$108 per sex worker over 9 months—would represent a substantial investment by the Kenyan Ministry of Health, which spent $70 per capita on health in 2002. Therefore, it seems unlikely that the female condom intervention could be expanded without donor assistance. In addition, because female condoms are currently much more expensive than male condoms, whenever the majority of female condoms are used as a substitute for a male condom there is limited public health impact from the intervention but there is a marked increase in cost.
The great uptake of female condoms by women who were already successfully using (mostly free) male condoms may be explained by several factors. Firstly, our monitoring reports revealed that peer educators' distribution of male condoms dropped by about half in the last 4 months of the study, which was probably because of the arrival of the Muslim holy month of Ramadan and a shortage of Ministry of Health condoms. Thus, study participants may have been “replacing” male condoms with female condoms because they did not have enough male condoms. Secondly, there is the novelty effect. It is not uncommon for a new product to take over a portion of an existing market, to be followed by a subsequent decline after the novelty wears off (as we saw here). Finally, in our formative research phase, Mombasan sex workers told us that they could secretly use the female condom with unsuspecting clients who would pay more for (seemingly) condomless sex. Thus, the female condom may have been picked up by sex workers as much for its money making potential as for its protective effects.
Continuing “condom gap” with boyfriends
Although our formative research indicated that the female condom had a potential role in filling the “condom gap” with sex workers and their emotional partners, introducing the female condom did not result in an increase in protected sex with boyfriends. A low risk perception with regular clients and boyfriends, and thus less insistence on condom use, is not uncommon in sex worker populations.2,19
Further, few male condom promotion programmes have been successful in increasing these levels, indicating limitations to peer education programmes that cannot be overcome simply by introducing a new device.13
The fact that consistent condom users in this study were less likely to have a boyfriend supports this conclusion.