The battle in Uganda over female condoms

On the surface, it seems like a fine idea; reproductive rights groups certainly think so. In July, the Ugandan government announced that, using cash from the U.N. Population Fund, it would distribute 100,000 female condoms in a bid to stop a resurgence of HIV/AIDS. Advocates cheered the initiative, saying it would give women more control over their own bodies. But in the weeks since, major funders of anti-HIV/AIDS programs have shown far less enthusiasm, with many deciding not to back the plan. Instead of serving as a surefire weapon against the spread of HIV, Uganda’s female condoms initiative has become the latest example of the limitations faced by governments, advocacy groups and donors in the fight against the virus. When Uganda announced its plan to hand out female condoms, it got plenty of support. “The number one issue for women is to be able to negotiate,” Serra Sippel, president of the Center for Health and Gender Equity in Washington, tells TIME. “The main issue was the desire for women to be able to say, ‘OK, you’re not going to use yours, then let’s use mine.’” In the fight against AIDS, say the advocates, any little bit helps. True, studies about the efficacy of female condoms are inconclusive. But, they insist, women, especially in Uganda, need as many choices as they can get. Many experts, however, disagree. They fear that by offering yet another choice, the government’s move may only distract from other drug and condom programs. “You can’t just put 100,000 condoms out in district warehouses and expect something to happen,” says Mike Strong, coordinator for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in Uganda. “Since we try to be an evidence-based operation, we’re waiting to see any evidence that this is a cost-effective method of protecting women against unwanted pregnancy and HIV transmission.” With funding so limited, many donors argue, why invest in an expensive product that faces deep skepticism from the people who would use it? Female condoms, originally introduced in the early 1990s, have struggled to gain widespread acceptance because they are more expensive and less familiar than male condoms — they’re big and baggy, make rustling noises during sex, and you need instruction and practice to learn how to insert them properly. But Uganda sees the female condom as one way to regain the success the nation had in the fight against HIV/AIDS in the 1990s. After slashing its AIDS rate from more than 20% in the late ‘80s to about 6% in 2000, Uganda saw a leveling off of AIDS cases and then a slight rise. No one has been able to explain the reversal. Some say it’s related to failed distribution programs for the male condom in the past. Other experts suspect that it’s a result of foreign NGOs and governments pushing Uganda away from effective domestic programs that were aimed at keeping people from having more than one sexual partner, a relatively common practice in the country. Stung by the failure of a female-condom initiative it tried 10 years ago, Uganda will start by distributing only the 100,000 female condoms it has in stock in two regions. The government says it has learned its lesson from the earlier program, and will put more effort into distribution and teaching people how to use the condoms. The government plan is partly a response to demand from civil society groups, who say Ugandan women are bearing the brunt of the AIDS epidemic. In a meeting on July 7, government officials agreed to start the program this year and extend it after a year if donors contribute more money. But even supporters of the program must confront the possibility that female condoms are simply not be effective in a place like Uganda. People in long-term relationships — male or female — are often less likely to use condoms. Yet that is exactly the group being hit hardest by the epidemic. A recent government analysis found that 65% of new infections occur among married people who have more than one long-term relationship at the same time. “Since so much transmission is taking place in long-term relationships, especially in Uganda, [female condoms] are unlikely to have much impact,” Helen Epstein, author of the book The Invisible Cure: Why We Are Losing The Fight Against AIDS In Africa, tells TIME. “The problem is the same as with male condoms. They signify mistrust, they are awkward to use, and they inhibit conception, which many couples want.” As an example, Epstein points to Zimbabwe, where donor groups tried to pass out female condoms and women simply removed the rings and used them as bracelets. “I am a skeptic about whether they will have even a minuscule effect on the epidemic in Africa,” she says. Proponents say the female condom just needs time to gain acceptance. They compare it to the tampon, which took 30 years to be widely adopted after being introduced in the 1930s. Women must have choices, they say. “We’re getting to the point where people are saying, ‘For God’s sake, anything that will stop this has got to be [available],’” says Anna Forbes, Deputy Director of the Washington-based Global Campaign for Microbicides. “We’ve paid the price in lives.” Even so, major donors including PEPFAR say they are not likely to back the female condom in Uganda. PEPFAR’s Strong says the female condom could occupy a niche market at best and the government is better off focusing on programs that already exist, not trying to start new ones. PEPFAR, for example, has distributed 133 million male condoms in Uganda in the last five years. “We haven’t done a very good job on promoting existing family planning products,” says Strong. “Why should we divert attention from pills, IUDs, and male condoms to what’s really a niche market? It can be nice to go off on a new pilot when old things aren’t working very well, rather than sticking around and trying to make them work.” TIME